Dopamine fasting

Dopamine

Taking a break from technology is a fine idea, but we don’t need a pseudoscientific new name for it: dopamine fasting.  Launched with viral Silicon Valley memes, online reports, and articles in the New York Times and elsewhere, dopamine fasting is now a thing.  Basically, the idea is to temporarily deprive oneself of the usual stimulations of life — largely electronic these days — in order to re-sensitize one’s brain.

Since several parties popularized the term, they wrestle over its definition.  Some take an ascetic, global view of stimulation-avoidance, while others limit the fast to electronic media.  Getting too excited over these battles stimulates dopamine, of course.  Perhaps it’s best not to worry about it.

Neuroscientists point out that the name is misleading.  Dopamine isn’t uniquely implicated in habituation to stimuli or behavioral addictions (although it is certainly involved), and naming the neurotransmitter doesn’t advance our understanding of the process.

Consequently, it’s no surprise pundits debunk the idea as repackaged common sense.  Sure, it’s refreshing to step away from the rat race and attention-grabbing tech.  But we already have names for that: relaxing vacations, a “mental health day”, picturing your happy place, meditating, taking a walk to clear your head, the sabbath, sabbaticals, retreat weekends, and so on.  The concept is as old as humanity.  This, in turn, leads proponents to defend their baby with heartfelt but not entirely rational distinctions between dopamine fasting and these other activities.

I’m in the debunking camp.  I agree with one of the vocal proponents of dopamine fasting, Cameron Sepah, who concedes: “The term is technically incorrect, but ‘stimulus control 101 for dealing with addictive behavior’ just doesn’t have the same ring to it.”  In other words, the term “dopamine fasting” is hype, referring (with false, dopamine-inducing excitement) to an old, well-understood behavioral practice.

It’s also the latest example of misleading the public with whiz-bang neurobiological language.   This is rampant in modern psychiatry, where the mere existence of functional brain imaging (allowing us to visualize metabolic activity in the brain) makes the field “biological” — even though our biological treatments haven’t improved as a result, and remain wholly symptomatic and empirical.

Attach a “neuro-” prefix or a brain chemical to your field of interest, and the world beats a path to your door.  I recently joked that if we re-cast psychotherapy as “verbal neuromodulation” the field would enjoy newfound popularity and research funding.  This is essentially what the advocates of dopamine fasting did.

Selling products with pseudoscience isn’t new.  Old-time cigarette ads, believe it or not, touted their health benefits.  Athletic clothing has been over-hyped to the tune of multimillion-dollar false-advertising settlements.  Cosmetic ads frequently invoke essentially meaningless scientific terms.

The difference now is that social media has made the “marketplace of ideas” a real marketplace.  Popularizing ideas, and by extension oneself, now demands the same promotional tactics previously used to sell cigarettes and soap.  Can you, in some convoluted way, tie your idea to neuroplasticity?  dopamine?  cellular regeneration?  If so, you’re well on your way to becoming an influencer.  Yes, you’ll be pandering to the attention economy, and presumably stimulating and thus depleting everyone’s dopamine in the bargain.  But don’t let that stop you.

Verbal neuromodulation: old wine in a new bottle

Neuromodulation is a hotly studied field.  Research groups worldwide are exploring genetic and epigenetic modulators, inflammatory processes, optogenetics, dietary effects, and other modalities.  Although neuromodulation can influence many non-psychiatric conditions, one tantalizing hope is that by modifying critical brain physiology and the connectome we may someday attack the root causes of mental illness, a global scourge of human suffering.

It may surprise the reader to learn that this tantalizing promise is, right now, an under-appreciated reality.

Neuromodulation is not a new idea; it has progressed over many decades with advances in medicine and technology.  Thanks to expenditures of many millions of dollars and fervent international effort, brain research now produces complex genetic maps and colorful three-dimensional depictions of metabolic activity known as functional brain imaging.  These visually engaging results suggest that we are closing in on the cellular substrate of the psyche.  Yet the linking of bench research to actual patient outcomes remains elusive.  When it come to psychological suffering, translational medicine seems so close and yet so far.

Oddly neglected in this juggernaut of neurobiological research is verbal neuromodulation.  Transmitted via phylogenetically primitive afferent auditory pathways, verbal signals enter along the eighth cranial nerves, then stimulate limbic and cortical brain centers in highly complex ways.  Simpler (nonverbal) auditory neuromodulation has been used successfully in treating tinnitus, i.e., ringing in the ears, and preliminary research has found that ultrasound can affect intact brain circuits.  But the neurobiological implications of higher-level auditory interventions have been overlooked — perhaps even denigrated — in a field beholden to high-tech reductionism.

In contrast to most neuromodulatory techniques, the verbal variety, historically known as “psychotherapy,” boasts a low-tech high-touch interface similar to everyday dialog.  Most human subjects have conversed since childhood and find the experience somewhat familiar and relatively non-invasive.  Generally well-tolerated and with a good safety record, psychotherapy has been shown to alter functional brain imaging and even brain microstructure, reflecting improved signaling in essential brain pathways.  Moreover, verbal neuromodulation is both “precision medicine” and “patient-centered,” concepts currently deemed crucial to patient care, not to mention academic advancement and publication in peer-reviewed journals.

While verbal neuromodulation has been shown to be highly effective in numerous studies, its mechanism of action is still not well understood.  At the neurostructural level, dialogic reflection may enhance bidirectional signal transduction between the limbic system, which mediates emotion, and cortical areas, which mediate cognition and self-awareness.  By bringing limbic and cortical centers into greater synchrony, the entire brain may work more harmoniously to realize its goals.  This synchronization is presumably mediated by enhanced dendritic arborization, resulting in a fuller connectome, and/or neuronal protein synthesis, allowing the consolidation of new memories.  Further research is surely warranted to delineate the fundamental mechanisms at play.

Verbal strategies to affect emotional well-being are not new.  Friends, family, clergy, counselors, and psychotherapists have conducted such interventions for generations.  Yet, in the 21st century, the “talking cure” has been supplanted by empty promises from neurobiology, while sufferers make do with dubious symptomatic treatments and quick-fix smartphone apps.  Re-casting dowdy, outmoded “psychotherapy” as verbal neuromodulation optimizes research grant support and may spark excitement in the public.  It may encourage more sufferers to reap the benefits of a brain-modifying treatment that long ago made the leap from theory to evidence-based practice.

Those of us who offer verbal neuromodulation should legitimately present it as the leading technology to target and modify specific brain activity in the service of relieving emotional suffering.  Of course, outside the earshot of pundits, academics, and a public entranced by high-tech, we may still call it psychotherapy.  Just as long as no one hears us.

Graphic courtesy of geralt at pixabay.com

Dialectics in psychotherapy

The word “dialectic” has a long history, from ancient Greek philosophers, through Hegel and Marx, and to the present day. Its meaning has changed over the centuries, and according to different thinkers. In psychotherapy, “dialectic” is almost wholly associated with dialectical behavior therapy (DBT), where the term identifies a particular type of treatment — even though most clients don’t know what the word means. In reality, dialectics as used in DBT is a feature of all schools of psychotherapy.

Broadly speaking, a dialectic is tension between two contradictory viewpoints, where a greater truth emerges from their interplay. Socratic dialog, in which philosophers mutually benefit by finding defects in each other’s arguments, is a classic example. In the early 19th century, Georg Wilhelm Friedrich Hegel described a universal dialectic, commonly summarized as “thesis, antithesis, synthesis.” His esoteric philosophy holds that every thesis, or proposition, contains elements of its own negation. Only by considering both the thesis and its contradiction (antithesis) can one synthesize a greater truth. This process never ends, as the new synthesis itself contains antithetical elements. The term veered in meaning with Marx’s dialectical materialism, and in yet other directions with more contemporary writers. But DBT uses the Hegelian sense, and that is our focus here.

Marsha Linehan faced a problem as she developed DBT in the late 1970s. Her behavioral strategies implicitly pathologized those she sought to help. Clients thought: “If I need to change, there must be something wrong with me.” To avoid re-traumatizing them, she turned to Zen Buddhism’s self-acceptance and focused on clients’ strengths. But this, in turn, downplayed their real need to change. Dr. Linehan and her colleagues eventually realized they would have to integrate change (thesis) and acceptance (antithesis) into a larger truth that incorporates both (synthesis).

This is the fundamental dialectic of DBT, although there are others. For example, the therapist is trustworthy and reliable, but he or she also makes mistakes. The client is doing his or her best but wants to do better. Although worded here using “but” for clarity, DBT teaches clients to use “and” instead (e.g., the therapist is reliable and makes mistakes). In doing so, the therapeutic task is to embrace the truth of both propositions at once, not to choose one over the other.

An uneasy tension between acceptance and the need for change exists in all psychotherapy, not just DBT. Indeed, this tension underlies a question commonly posed to new clients: “What brings you in now?” Therapy begins only when emotional discomfort and the perceived need for change outweigh the inertia (i.e., acceptance), reluctance, and other factors that precluded it before. Then, once in therapy, change versus acceptance is often an explicit struggle. File for divorce or work on one’s marriage? Learn to be bolder or accept that one is shy by nature? Change physically through exercise or plastic surgery, or become more comfortable with the body one has?

When clients grapple with such questions, therapists of any school should refrain from choosing sides or giving advice. Except in extreme cases, we simply don’t know which option is best for the individual in our office.

However, it goes further than this. As Hegel wrote, a clash of thesis and antithesis may result in a new third way, a synthesis that incorporates, yet transcends, both sides of the argument. This “union of opposites” was first described by pre-Socratic philosophers (and by Taoists, as in the well-known Yin-Yang symbol of interdependence). The concept was later adopted by alchemists, who observed that compounding two dissimilar chemicals can result in a third unlike either parent (e.g., sodium, a highly reactive metal, plus chlorine, a poisonous gas, produces table salt). Carl Jung, who studied alchemy, weaved the union of opposites into various psychological writings. It forms the basis of his “transcendent function” that leads to psychological change; an accessible introduction to this concept can be found here.

The shuttling to and fro of arguments and affects represents the transcendent function of opposites. The confrontation of the two positions generates a tension charged with energy and creates a living, third thing… a movement out of the suspension between the opposites, a living birth that leads to a new level of being, a new situation.

Collected Works of C. G. Jung, Vol. 8. 2nd ed., Princeton University Press, 1972. p. 67-91.

One need not be a Jungian to recognize creative, “third-way” processes in therapy. Instead of being caught on the horns of a dilemma, it often helps to take a step back and appreciate the validity of both positions: It is valid to seek autonomy and relatedness. It is valid to be serious and to play. And it is certainly valid to accept oneself while also striving to change. Insight is our term in depth psychotherapy for achieving synthesis: a position that reconciles and transcends thesis and antithesis, makes sense emotionally, and works in one’s life. In this way, dialectic tension generates all creativity and psychological growth.

Image courtesy of digitalart at FreeDigitalPhotos.net


"Evidence based" psychotherapy

When a mental health clinic, online referral service, or private practice offers “evidence based” psychotherapy, that certainly sounds like a selling point.  It suggests solid science supports the therapy offered — and that competing services lack this support.  But what does this phrase really mean?

“Evidence based medicine” first appeared in the medical literature in 1991.  It cast doubt on physicians’ clinical intuition and anecdotal experience, reminding them that science should guide medical practice.  (The term was new, the warning was not.)  Acceptable scientific evidence included clinical epidemiology, bench research, published case reports, and so on.  However, the randomized controlled trial (RCT) soon emerged as the gold standard, the best evidence that a treatment works.

In a RCT, subjects who all suffer the same disease are randomly assigned either to the treatment under study, or to a control group.  The latter receives an inactive placebo, or sometimes an active comparison treatment.  Ideally, RCTs are “double blind”: neither the subjects nor those rating them know who is in which group.  This minimizes psychological effects such as confirmation bias, where both researchers and subjects tend to rate more improvement where they expect to see it.  If the treatment group then fares better on average, this is taken as strong evidence of treatment efficacy.

RCTs are powerful tools — with limitations.  Best for studying a single treatment applied to a single disease, the method becomes impractical when studying patients with multiple or ill-defined conditions, or when assessing treatments with nuanced variations.  It can be hard to find a suitable placebo or comparison treatment, and sometimes it proves impossible to create double-blind conditions.  For a variety of reasons, there is still an important role for evidence aside from RCTs.

In the field of psychotherapy, the paradigm in the first half of the 20th century was psychoanalysis and its offshoots.  Its prominence was largely due to intellectual elegance and compelling case reports, not RCTs.  But by mid-century, critics began questioning the broad claims of psychoanalysis.  New medications and psychotherapies were introduced.  And in 1980, psychiatry’s Diagnostic and Statistical Manual was revised.  It would thereafter define mental disorders not narratively, but by symptom criteria.  With the right set of symptoms, a patient would “meet criteria” for one or more diagnoses.

Drug developers and the newer schools of therapy, especially cognitive behavioral therapy (CBT) and short-term structured therapies, were eager to prove they could reduce these symptoms and, by definition, relieve psychiatric disorders.  Many RCTs were done, and indeed these studies showed, on average, that symptoms were reduced.  This led to FDA approval for the medications, and to “evidence based” claims for the therapies.

Yes, CBT and other symptom-focused therapy is “evidence based.”  But that’s only part of the story.  Left unsaid is that a great deal of scientific evidence finds traditional, psychoanalytically based therapy effective as well.  This includes group studies using standardized measures — even RCTs — as well as patient satisfaction surveys, a myriad of case reports, and other lines of evidence.  Although there are fewer RCTs of analytic therapy than CBT, often the amount of improvement (the statistical “effect size”) is greater in the former.

“Evidence based” also glosses over why people seek therapy.  Many hope to decrease concrete symptoms: to feel less anxious, to have a brighter mood, to sleep more soundly.  Here the evidence supporting CBT and similar treatments is very solid.  But others are motivated by vague complaints that arise only in the context of close relationships.  Or by a lack of meaning in life.   Or by unwitting self-sabotage.  Not uncommonly, they really can’t say what is wrong.  No RCTs exist for such problems, as there is no diagnostic group to randomize, no concrete symptoms to treat.

It reflects a fundamental misunderstanding — or false advertising — to promote “evidence based psychotherapy” for these sufferers.  There is no such evidence, if by that we mean RCTs.  Yet if evidence is more broadly construed, as it was in the original conception of “evidence based medicine,” it is psychoanalytic therapy, not CBT, that is supported by far more evidence.

“Evidence based therapy” has quickly become an empty phrase that slights the competition.  The evidence is real, but its relevance often is not.  This false narrative has misled insurers, government agencies, and many patients into believing certain approaches to psychotherapy are inherently superior when they are not.

Cognitive, highly structured, symptom-focused therapies certainly help many people.  Psychoanalytic therapies, and other therapies that rely on depth and relatedness, do as well.  The best choice for an individual depends on factors unique to that person, starting with his or her presenting complaints and preferences.  It may or may not be relevant that a particular therapeutic approach works against specific symptoms as tested in RCTs.  “Evidence based” is mostly sales-talk, not a blanket scientific endorsement.  All mainstream psychotherapy is evidence-based.

Image by Gerd Altmann from Pixabay

Psychiatry's hubris

Is it fair to take a balanced, well researched critique of psychiatry, and use it as a springboard for polemics? It wouldn’t be the first time. This week, in reviewing Anne Harrington’s upcoming book, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, psychiatric critic Gary Greenberg champions the measured points made by Harrington, then extends them into illogic and name-calling.

Harrington, a Harvard historian of science, chronicles psychiatry’s efforts over more than a century to account for psychiatric ills biologically. As her title says, it’s been a troubled search. Some practices, like lobotomy and ice-water hydrotherapy, are now seen as cruel and barbaric; once-popular “chemical imbalance” theories are now discredited. The smug assurance in recent decades that all psychiatry is neurobiological does indeed reflect hubris. It is said as though this were an empirically validated discovery. It is not.

Greenberg, writing in the April issue of the Atlantic magazine, has no quarrel with these observations, and indeed offers no substantive criticism of Harrington’s book. His main beef is that she is too nice. For Harrington is committed to restraint, noting that war between psychiatrists and anti-psychiatrists results in “tunnel vision, mutual recrimination, and stalemate.” She believes it should be possible to critique psychiatry, its past errors and even its current ones, without throwing the baby out with the bathwater.

Greenberg is a psychotherapist and author who has himself been profiled in the Atlantic. An outspoken critic of psychiatry’s Diagnostic and Statistical Manual (DSM), he doesn’t think much of us psychiatrists either:

It’s the universal paranoia of psychiatry that everybody who disagrees with them is pathological. You can’t disagree with a psychiatrist without getting a diagnosis.

This, of course, is untrue. I’ve never heard any psychiatrist diagnose Greenberg, or Thomas Szasz or Robert Whitaker for that matter. We’re all adults here, and we can disagree without calling each other names.

Meanwhile, back at the book review, Greenberg oddly cites the unknown mechanism of action of antidepressants as evidence they don’t work:

At last count, more than 12 percent of Americans ages 12 and older were taking antidepressants. The chemical-imbalance theory, like the revamped DSM, may fail as science, but as rhetoric it has turned out to be a wild success.

Greenberg apparently believes that 12 percent of Americans take antidepressants because their doctors falsely claimed they suffered a chemical imbalance. There is no evidence for this, and it’s highly unlikely. Much more likely is that these many patients sought symptomatic relief from depression or anxiety, and a prescriber believed an antidepressant would relieve their unwanted state of mind.

It doesn’t take knowledge of a drug’s mechanism of action to rationally prescribe it. The history of medicine abounds with empirical treatments, i.e., ones that worked although we didn’t know why. Aspirin is a good example: it was used effectively for generations before anyone had an inkling how it worked. Thoughtful psychiatrists embrace uncertainty and refrain from making unsupported claims about treatment. But absence of evidence is not evidence of absence. Psychiatric medication helps a great many people — admittedly not everyone, and not without cost — and there is no shame in prescribing it while admitting we don’t know why it works.

Greenberg later complains of an:

industry that touts its products’ power to cure biochemical imbalances that it no longer believes are the culprit. Plain bad faith is what’s on display, sometimes of outrageous proportion.

While I was an early critic of chemical-imbalance claims myself, I believe Greenberg’s argument is stale. Drug companies don’t push presumed mechanisms of action much anymore. The psychiatrists who still do are acting out of false pride in their scientific acumen, or perhaps to persuade hesitant patients to start treatment. These aren’t justifiable reasons, and psychiatrists shouldn’t act this way. But calling it bad faith is… bad faith. Greenberg also lumps drug companies, the American Psychiatric Association, and psychiatrists into an “industry.” As a solo practitioner with a largely psychotherapy practice, this is news to me.

The review ends with Greenberg quoting Harrington and then editorializing in a particularly dismissive way. Harrington ends her book by advising psychiatry:

“to overcome its persistent reductionist habits and commit to an ongoing dialogue with … the social sciences and even the humanities.”

Greenberg agrees with this advice, as do I. But he is pessimistic, and ends with his own diagnosis, that psychiatry’s hubris is incurable:

But no matter how evenhandedly she frames this laudable proposal, an industry that has refused to reckon with the full implications of its ambitions or the extent of its failures is unlikely to heed it.

Greenberg himself falls prey to the “tunnel vision, mutual recrimination, and stalemate” Harrington warns us about. Psychiatry is not an “industry”; the number of American psychiatrists (about 28,000 this year and dropping) pales in comparison to the number of clinical psychologists and other licensed mental health professionals. Drug manufacturing is certainly an industry, and we physicians must draw ethical lines around undue influence by these far more powerful and monied firms. Our APA should as well. The resulting picture is not of a psychiatric juggernaut, but of a largely disorganized profession asked to solve social ills while being eyed suspiciously. And while being battered by an under-regulated pharmaceutical industry, which also advertises directly to the public. The U.S. is nearly unique in the world regarding direct-to-consumer drug ads.

Is psychiatry hubristic? Certainly. Claiming to know things we don’t about neurobiology, claiming to hold authority over other mental health professionals like psychologists, claiming our time is worth more — yes, all of these reek of hubris. Many critics within psychiatry have pointed this out, and argue for more humility within our ranks. There are also valid critiques that as a group we are too quick with the prescription pad, and that we should conduct, or refer patients to, psychotherapy more than we do. There are many ways psychiatry can improve. But taking potshots at us doesn’t help, and dismissing us as incurable is the very definition of bad faith.

Finally, why would the Atlantic choose an outspoken critic to review a book about psychiatry? The publishers weren’t really expecting a balanced, measured review, were they?

Dynamic therapy as 'Alternative medicine'

“Complementary and alternative medicine” (CAM) is a category that includes all the methods of physical or mental healing that do not fall under the umbrella of western medicine. Examples include comprehensive healing traditions from other cultures, such as Chinese or Ayurvedic (Indian) medicine; herbal remedies; and a wide variety of mind-body treatments, such as meditation and yoga. CAM treatments are popular everywhere, including here in the U.S. But they are considered unproven by western medicine, usually because they haven’t shown statistically significant treatment effects, as compared to placebo, in randomized controlled trials (RCTs).

Advocates of CAM argue that RCTs are the wrong tool to assess such treatments. Western medicine is founded on diagnosing a disease, then applying one or more treatments known to fight that disease. Individual differences among patients who share a given disease are considered error variance that can’t be accounted for. These differences are averaged out in subject groups, which is why large subject groups lend more statistical power to RCTs than do small subject groups. Thus, antidepressant drugs and cognitive behavioral therapy (CBT) are accepted as legitimate in western medicine because research subjects with diagnosed major depressive disorder improve — on average — with these treatments to a greater degree than similar patients in control groups. Differences between responders and non-responders in a given group are usually unstudied and unknown, and in any case irrelevant to the finding that the treatment is “effective.”

A common feature of CAM is that individual differences are highlighted, not thrown away as noise. Chinese and Ayurvedic medicine describe subtle balances of tendencies or energies within the individual, and seek to restore health by correcting imbalances. Similar principles are purportedly at work in chiropractic, western herbalism, tai chi, and so forth. It remains an empirical — but often hard to test — question whether these CAM practices actually have a healing effect.

Psychodynamic psychotherapy (and for purposes of this discussion, psychoanalysis) is not considered CAM because it does not fall outside the umbrella of western medicine. Dynamic principles are taught to psychiatry residents (i.e., physicians), health insurers pay for treatment, and non-psychiatric physicians have few qualms about referring their patients for such therapy.

However, this is changing. The term “evidence based treatment” is increasingly used to differentiate psychiatric interventions that fit the standard RCT paradigm. These include FDA-approved medications and other somatic treatments such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS). They also include CBT in its various forms. Notably, dynamic therapy and psychoanalysis are not included, despite a sizable literature showing efficacy. “Evidence based treatment” is thus a misleading term, a kind of sales pitch for certain types of treatment. But it’s an effective sales pitch. It is becoming “common knowledge” that some psychotherapy is “evidence based” and some is not. There are only small, fledgling efforts thus far to counter this misperception.

Dynamic therapy is thus veering from mainstream legitimacy to something approaching CAM. It’s no coincidence that it also shares important commonalities with CAM: a focus on individual differences, subtle energies (unconscious impulses and feelings in this case), a “balancing” paradigm within the individual, and a rejection of one-size-fits-all treatment.

On the one hand, it is small comfort that psychodynamics now joins company with implausible healing arts such as reiki and homeopathy. It feels unfair to discount our careful theories, myriad case reports, our documented successes. We’re not some crackpot cult positing invisible entities and forces, like chakras, kundalini, and chi. Except that, in the eyes of many these days, we are. It can all be a bit depressing.

On the other hand, sometimes CAM eventually gains legitimacy even in the eyes of western medicine. Acupuncture and probiotics are arguably two such examples. Perhaps the pendulum will swing back when more sophisticated research methods show unique advantages for dynamic treatments. Or more simply, when “evidence based” isn’t accepted blindly.

In the meantime, given the unfortunate delegitimization of dynamic treatment, practitioners may be well served to embrace its undeniable and laudable kinship with CAM. “Precision medicine,” a buzzword these days, rightly applies not only to genetic testing and personalized pharmacology, but also to individualized psychological treatment. Focusing on the person and not the disease need not be the sole province of eastern healing philosophies. Attention to subtlety and nuance need not be relegated to mystical, esoteric practices. In all these areas, the dynamic tradition has been there and done that.

Ten years of blogging

This month marks a decade of blogging on “Reidbord’s Reflections.” This is the 130th post. My posting frequency dropped precipitously over the years, from 20 posts in the first two months to one every couple of months now. I imagine I share with most bloggers a limited set of rehearsed topics, things I always wanted to write about. Once these were exhausted, new ideas came more slowly, often spurred by news articles.  Lately I’ve been more inclined to write about current events and news items, less about psychiatry.  I find people’s minds and ideas engaging.  As for the practice of psychiatry — tweaking this med or that, arguing over nuances of psychotherapy technique, weighing ethical goods like beneficence and autonomy — well, my interest waxes and wanes.  Psychiatry doesn’t change quickly, and as a result I feel little time pressure to write about anything particularly psychiatric.

I don’t track my readership here, but I crosspost to a blog on Psychology Today’s website, and they keep records. Far and away, my most read post there is “Countertransference, an overview” with nearly 400,000 views.  It’s fairly well written in my humble opinion, but not especially so.  I can’t account for its outsized popularity.  Other favorites of mine, never mind their popularity, include the two-part posts on placebos and psychiatric disability; my ethics piece on Pharma and doctors; my post on charging patients for missed sessions (with a record 130+ comments); “Antidepressants are just a crutch“; my sailing analogy; whether therapists should accept gifts; and my one attempt at fiction.  Actually, there are more, but I’ll stop there at ten.

Also, I was surprised to learn that my “Brief History of Psychiatry,” a page deep in the website for my practice — not in my blog — is quite popular.  It’s often found by folks searching for… a brief history of psychiatry.  As it happens, roughly 50% more people search this phrase and go directly to that page on my site, than search for psychiatric services and go to my landing page.

I somewhat regret naming my blog after myself.  If I’d known I’d be at it ten years later, I might have thought harder about a better name.  I envy the creative titles of some psychiatry blogs: Shrink Rap, Thought Broadcast, The Alienist, 1 Boring Old Man, The Last Psychiatrist.  Sadly, however, none of these are active anymore.  Dinah Miller shut down Shrink Rap in August, Mickey Nardo (“1 Boring Old Man“) died nearly two years ago, The Alienist stopped posting in 2015, the anonymous Last Psychiatrist went silent in 2014, Thought Broadcast in 2013.  Psych Practice and Psycritic haven’t posted for over half a year, either.  It’s nice to see George Dawson still posting long, thoughtful, frequent pieces on Real Psychiatry, even if I sometimes disagree with his conclusions.  There are, of course, other psychiatry blogs I’m less (or not) familiar with.

I was pleased that a content aggregator called Feedspot ranked “Reidbord’s Reflections” number six out of the “top 50” psychiatry blogs and websites.  I don’t know how they decided this, but I thank them nonetheless.  I even added their badge to my blog several months ago.  I didn’t pay them or anything.

The future of this blog? With the demise of Shrink Rap, a longtime favorite, it crossed my mind to shut down too.   I realized early on that the 1000-word cerebral essay isn’t ideal for blogging.  It’s not my style to post quickly and often, nor to repost cute cartoons and jokes from other sites.  By only occasionally posting anymore, I imagine that long ago I lost the regular readers I once had.  (I miss the dialog we sometimes had in the comments in the early years.)  I’ve thought about turning some of this writing into a book.  Or maybe try more seriously to publish op-eds in old-fashioned newspapers.

On the other hand, I’d feel bad to kill this creature I created.  On balance, I figure I’ll keep posting here as ideas occur to me. I enjoy writing (and crossword puzzles, and other wordplay).  As long as it’s fun there’s no reason to stop.  And you’re more than welcome to keep reading — and commenting, and even tossing me a writing-topic suggestion now and then.  It’s good to have you along.

The photo is an iPhone calendar from 2008.