November 2nd, 2024
Last week I met with a patient of mine. He’s a sweet, kind middle-aged man without a hostile bone in his body. He and his brother both have schizophrenia. Both of them fear psychosis and cooperate fully with psychiatric care to keep it at bay. My patient is the higher functioning of the two, and often takes his brother to the movies. I learn about new movies this way, since my patient usually sees them before I do.
Last week he and his brother watched the first 15 minutes of the new “Joker” movie starring Joaquin Phoenix and Lady Gaga. They walked out when the villain was depicted as mentally ill, and the psychiatric hospital a nightmare dystopia.
We talked about how psychiatrically disabled people are demonized in movies and elsewhere. Insanity seems to be an evergreen choice for movie villains. From Norman Bates in “Psycho” to Hannibal Lecter and Buffalo Bill in “Silence of the Lambs,” from Batman’s adversaries to Michael Myers in the “Halloween” series, the viewing public never seems to tire of scary, mentally ill characters.
Other demonized groups come and go. For example, I recently watched the original “Mad Max” from 1979. The bad guys were apparently bisexual and gender-nonconforming in that one. That wouldn’t fly today. For a long time in many popular movies it was Communists, and then after 9/11, it was Arabs or Muslims.
Even when there’s an element of truth to these prejudices, e.g., the reality of 9/11, or the occasional violent person with psychosis, a lot of innocent folks get trapped in these stereotypes. Most Muslims aren’t violent. Most people who have schizophrenia or dissociative identity disorder (“split personality”), the usual diagnoses of the cinematically insane, are not dangerous, or homeless, or offensive in any way. They’re mostly suffering and scared — and more often the victims of violence than the perpetrators.
What’s the best solution? Casting all movie villains as straight cisgender WASPs wouldn’t be fair to that group either. Is there a plausible “fair distribution,” to smear everyone equally? Is there a non-silly way to make movie villains not resemble any real people — make them all purple or something? None of these seem realistic. Are we stuck catering to existing negative stereotypes?
I don’t have a solution. All I can say is, it’s plainly wrong to pick on a disabled population. I felt bad for my patient. He never hurt anyone in his life, yet couldn’t take his brother to a movie in wide release without feeling personally vilified on the big screen.
September 1st, 2024
A Target of Ridicule
The Left Responds
The left responded with outrage, using three main arguments. First, some say Gus shouldn’t be subject to media attention at all. There was once implicit agreement, although often observed in the breach, to spare the minor children of politicians.
However, it’s easy to point to prior violations: unkind commentary about Tricia Nixon, Amy Carter, Chelsea Clinton, the Bush daughters, the Obama daughters. Barron Trump has largely escaped scrutiny, raising important questions about the sexism implicit in such negative attention. That Gus Walz has been treated with similar contempt may reflect the feminization of emotion in the minds of critics. In any case, many feel it’s a low blow to force any minor, including Gus, to bear the brunt of political scrutiny.
I hesitated writing this post for that very reason. But it’s a moot point: if widely read newspapers print opinions about Gus Walz, my doing so too hardly matters.
Second, the MAGA right is once again making fun of someone’s disabilities — a child in this case. Doing so recalls Donald Trump ridiculing Serge Kovaleski, a reporter with a congenital joint condition called arthrogryposis. This is plainly cruel and should be beneath the dignity of any adult, much less politicians elected to represent the public.
And third, many on the left honor Gus Walz as a role model, to the point that they argue that focusing on his neurodivergence is the wrong message. They say he demonstrates men’s capacity to express tender feelings. Many call his emotionality touching and admirable — something to emulate. It’s this third argument that brings Gus into the center of the culture wars.
Male Emotional Expression
Gus Walz unwittingly serves as a perfect symbol of this cultural rift. To the left, he represents being in touch with feelings, even allowing oneself to be swept away in the moment. Losing one’s composure is sincere and vulnerable — more genuinely human. In a world of macho posturing and aloofness, Gus is a beacon of light.
Yet to the right, Gus Walz represents all that is wrong with the left. Men and boys are different than women and girls. The former are ideally tough and in control of themselves; the latter are called the weaker sex for a reason. Emotions such as patriotism, anger, and competitiveness are manly, tears and vulnerability are not. Lauding Gus Waltz’s emotional instability reveals the weakness of the left — and the risk this weakness poses for society at large.
Who’s Missing? Gus Himself
The problem with this political analysis is that it leaves Gus Walz, the person, out of the discussion.
He’s very likely mortified by all the attention focused on his tears, whether from the left or the right. Who wouldn’t be, particularly as a teenager? Avoiding undue attention is far more important to most teens than any political or cultural meaning others project onto them. Gus Walz didn’t sign up to be the poster boy of open emotionality, and would surely decline the honor if asked. How do you imagine he feels, seeing his weeping face everywhere in the news — even from those who admire him?
The Liability of Being a Cultural Symbol
Emotional aloofness is limiting and unhealthy. But being too emotional has its drawbacks too. It can be a social liability, a source of shame, a blow to one’s self-image.
June 1st, 2024
Over a decade ago, I noticed a new term cropping up in psychiatry: anosognosia. Actually, it was an old term, coined a century earlier by neurologists to describe a behavioral sign in certain types of brain damage. But by the time I took notice, this mouthful of a word was doing double duty. In neurology it still referred to peculiar deficits of awareness linked to specific anatomical damage in the brain. In psychiatry it began to mean something else.
I wrote a blog post in 2011 on the misuse of “anosognosia” in psychiatry, a word that had come to mean the denial of illness often seen in severe psychiatric disorders. Psychiatry already had a perfectly good phrase to describe this denial: lack of insight. By my reckoning, replacing this with a neurological term was a rhetorical trick, “intended to make psychiatry sound better understood, and more biological/neurological, than it really is.”
Insight is subjective
At the time, I emphasized subjectivity in assessments of insight. This is reflected in the common observation that psychiatric patients have “good insight” if they agree with their psychiatrists, and “poor insight” otherwise. Given the many reasons one might differ with one’s psychiatrist, from delusions to honest conceptual disagreements, “anosognosia” seemed a crude way to pathologize disagreement.
It’s now 2024, and “anosognosia” is alive and well in popular media about mental illness. It’s a word pushed by treatment advocacy groups, less so by psychiatrists. In view of its tenacious foothold, I’d like to revisit this formerly obscure term, with a somewhat different spin than I gave it 13 years ago. It’s not so much the subjectivity of insight I want to emphasize now, but the political use of language.
Neurology uses “anosognosia” precisely
Coined in 1914 by the neurologist Babinski, for a century “anosognosia” meant denial or lack of awareness of disability due to injury or disease of specific parts of the brain.
One example is “hemi-inattention”: lack of awareness of one side of the body, or one side of the visual field, due to parietal lobe damage. For example, a patient with a right-hemisphere stroke may be unaware that his or her left arm is paralyzed. Such a patient, when asked to draw a clock face, may add numbers only to the right side, neglecting the left completely. Or notice a stimulus in the right visual field (of both eyes), but not the left. This is hemi-inattention. Other early examples included cortical blindness and cortical deafness, sensory deficits that the patient may be unaware of, due to damage in the cerebral cortex.
Prior to the invention of brain imaging, e.g., CT scans in the 1970s, neurologists could determine the site of brain damage, most often in the parietal lobe, by the presence of anosognosia. It was, and is, a neuroanatomical localizing sign. One of the special skills of the neurologist is to localize nerve or brain dysfunction by careful assessment of signs and symptoms.
Later, neurologists applied “anosognosia” to lack of awareness of deficits in some types of dementia, due to specific frontal lobe damage. This is again a neuroanatomical localizing sign.
Words can slip in meaning
Unfortunately, the application of this word in dementia may have misled lay observers (and a few die-hard biological psychiatrists) to conclude that lack of illness awareness in schizophrenia and manic psychosis is anosognosia as well.
I should digress here to acknowledge that words, especially psychological words, often change their meanings over time. “Idiot,” “moron,” and “imbecile,” all words that now roughly mean “stupid,” once had precise psychological meanings. “Narcissism” and “gaslighting” have devolved from highly specific terms to general terms of disapproval. If one likewise wants to argue that “anosognosia” once meant something very specific in neurology, but now means general cluelessness or lack of insight, I can’t really say that’s wrong. I can only regret that a once useful word has been dumbed down in the service of political rhetoric.
A veneer of pseudoscience
“Anosognosia” in psychiatry offers nothing more than a veneer of pseudoscience. There’s no evidence that lack of insight in schizophrenia is related in any neurological way to the lack of insight in anorexia nervosa. Yet “anosognosia” has been applied in both. Conversely, patients with ego-syntonic personality disorders also lack insight and deny their illness, but the term is not applied there, because these disorders don’t seem “biological” enough to lay claim to a neurological term.
More fundamentally, there is no neuroanatomical localization in psychiatric disorders — by definition really. As I’ve often noted, whenever a psychiatric condition is localized and understood medically, it inevitably leaves psychiatry, to be claimed by neurology or another branch of medicine. Psychiatry is what’s left. The only thing “anosognosia” adds to “lack of insight” is the implication that (some) “psychiatric disorders are brain diseases.”
As I’ve also repeatedly argued, this is political rhetoric, not science. The reality is far more complicated. Psychiatric disorders differ widely in the degree to which they appear biological, yet even the most biological-seeming have strong psychological components.
Anti-psychiatrists often claim there is no biology in psychiatry at all — that it’s all social control, punishment of deviance, and the like. Conversely, treatment advocacy groups and some biological psychiatrists seem to believe it’s all biology.
False certainty helps no one
Both groups are mistaken. Psychiatry is fundamentally uncertain and in-between. Yes, there’s biology. And yes, there are social factors at play in psychiatric assessment (and functioning) as well. Even in psychosis, a patient’s degree of insight can fluctuate in response to stress and other environmental factors. It’s not, as the neurologists might say, a fixed deficit.
As I wrote 13 years ago, the use of “anosognosia” is a rhetorical device to make insight judgments in psychiatry sound more biological/neurological, without offering any particular reason to do so. This misuses the term, and lays claim to unwarranted certainty in an inherently uncertain domain. Like “chemical imbalance” and other convenient oversimplifications, it’s understandable that untrained laypeople might make this mistake. It’s more disappointing when mental health professionals do, especially when they really should know better and be more honest.
May 4th, 2024
The application of palliative care to intractable psychiatric disorders has been debated at least since 2010, when a journal article reported that a patient with severe anorexia nervosa died in hospice, after referral there by her psychiatrist. The New York Times published a thought-provoking article earlier this year on the same topic: whether we should ever deem severe, treatment-refractory anorexia incurable and terminal.
Are there incurable psychiatric patients?
Proponents argue that only hubris and false hope on the part of psychiatrists stand in the way. They say we should treat such patients as our colleagues treat medically incurable patients: with palliation and hospice.
This question is vexing enough. But eating disorders are an exception in psychiatry: untreated, they can lead to death from medical causes. Other mental disorders are miserable but not terminal in the same way.
Medical aid in dying
For this reason, discussions of “palliative psychiatry” lead directly to medical aid in dying (MAiD). Although MAiD solely for psychiatric conditions is not legal anywhere in the U.S., laws permitting it exist in Belgium and the Netherlands, and are pending in Canada. Accepting the framework of palliative psychiatry for incurable conditions appears to entail MAiD.
However, arguments that advocate for palliative psychiatry are muddled in several ways, and do not in fact lead to that conclusion.
Psychiatry is already palliative
First, psychiatry is inherently palliative. All somatic psychiatric treatment (medication, ECT, TMS, and so on) treat signs and symptoms of psychiatric disorders, not their root causes. That’s because we don’t know these root causes, nor the mechanisms that connect them to the manifest signs and symptoms we observe. In essence, all such treatments aim to provide symptom relief, comfort, and support — the very definition of palliative care. It makes no sense to speak separately of palliative psychiatry when palliation is virtually the whole field.
The only exception is psychotherapy. Psychotherapy aims to treat the root causes of emotional distress. Of course, this can succeed or fail, and in the case of failure we and our patients routinely resort to palliation. This is called supportive psychotherapy. It’s hardly a new concept that needs a new name.
Treatment resistance is slippery
Second, arguments for palliative psychiatry usually invoke “treatment resistance,” or refer to “treatment-refractory” disorders. Disorders so named are the putative targets of palliation, since we can’t “treat” them.
There are biases hidden in such language. Treatment resistance is a concept from biological psychiatry. It means a particular patient fails to improve in the face of somatic treatments that help most other patients. However, as David Mintz argues, adding psychotherapeutic elements to a medication treatment can overcome this kind of treatment resistance. From a psychotherapeutic standpoint, treatment resistance may say more about the treatment than the patient.
Psychiatric disorders are not “things”
Psychiatric disorders sound misleadingly like reified “things” we can treat with concrete interventions. In reality, our moods, thoughts, impulses, and actions result from a complex interplay of biology and psychology. Treatment resistance in that light is vague and abstract — not a sound basis for life and death decisions.
Again in contrast, psychoanalytic psychotherapy is well-acquainted with treatment resistance. In fact, it’s expected. Not only is resistance not a reason to give up, it can be a signpost to insight and improvement.
Personality change can take a long time. I saw a highly defended patient in weekly psychotherapy for several years before she allowed herself to be vulnerable and introspective. In the years before the change I often wondered if we were wasting time and money, if she was “treatment refractory.” Now we both see that she isn’t. Conversely, I’ve seen another patient even longer with little to show for it. Is he incurable? There’s no way to know.
Being present and bearing witness
Third, sensitive psychiatrists (and other mental health professionals) stay with our patients whether they improve or not. The original idea behind palliative care was attending to the patient’s “total pain,” which includes the physical, emotional, social, and spiritual dimensions of distress. Not listed but equally important is bearing witness to distress, and maintaining a caring therapeutic relationship come what may. Again, we offer palliation in nearly everything we do.
MAiD is never inevitable in psychiatry
Last but not least, given all of the above, MAiD cannot follow as a logical next step even after long-term hopelessness or failure to improve psychiatrically. Staying present isn’t hubris and it isn’t imparting false hope. If a patient chooses to forgo further treatment, whether somatic or psychotherapeutic, we will honor that choice and remain available. If local laws someday allow, and as a matter of personal conscience, some of us may choose to participate in MAiD. But that will be an individual matter quite separate from incurability, treatment resistance, or comparisons with terminal medical conditions.
December 31st, 2023
Two senses of “psychotherapy is political” are often conflated. The first is the notion, popular lately, that psychotherapy either allows or demands political advocacy in the therapy room itself. The other is recognition that political factors influence the nature and practice of psychotherapy. It is a conceptual error to confuse the two, and a clinical error to justify the former by appeal to the latter.
Yes, psychotherapy is political (like everything else)
Viewing the practice of psychotherapy through a political lens, albeit one lens among many, can be valuable and revealing. Political analysis of this sort can be applied to nearly all human endeavors: war, housing, work, romantic relationships, childrearing, sports, nutrition, medical care, media, etc. There is no reason to imagine psychotherapy is an exception, and indeed it is not. To cite just a few of the most obvious areas where politics intersects with psychotherapy:
- third-party payment, public and private, and out-of-pocket cost
- the choice of psychotherapy versus other types of help
- social stigma, both of mental disorders and their treatments
- social inequities that lead to despair, anxiety, and anger
- controversies over what counts as a mental disorder
- lobbying and other activities of professional organizations
- allocation of research funds
Note that none of these dictate how therapy itself should be conducted, aside from the value of understanding and appreciating what the patient is dealing with. In other words, for empathy. None of these political issues speak to what psychotherapy is, or realistically offers. Even issues such as gender and racial dynamics within psychotherapy itself, while important to be aware of, need not alter the way competent therapy is conducted.
One political view that matters
However, there’s a different kind of political position that does affect psychotherapy itself. It’s the degree to which one situates pathology in the sufferer, versus in his or her environment. Even Freud grappled with this. His early “seduction theory” held that childhood sexual abuse led to neurosis. Yet he was unable to believe such abuse was widespread. Thus, he soon revised his account to say that young children had sexual (or sexual-like) fantasies that led to inner conflict. This revision justified treatment of the individual who harbored the conflictual fantasies.
Conversely, some therapists today hold that emotional distress and dysfunction are always “normal reactions to abnormal situations.” That is, the pathology lies outside the patient. This perspective justifies social action, not inner exploration.
Where patients locate pathology affects how and whether they seek therapy. Those who frame their problems as existing entirely outside themselves — cruel bosses, uncaring spouses, or social pathology such as racial, gender, or class inequity — don’t come to therapy to change anything about themselves.
Externalization
In the traditional language of psychotherapy, such patients externalize: they complain about the outside world, which psychotherapy can do nothing about, and disclaim responsibility for their plight. Typically, therapists are quick to challenge this stance when it comes to difficult bosses and spouses. After all, therapy can’t change other people, only the patient.
Curiously, despite identical logic, many therapists today accept externalization with respect to social ills. They see their role as providing support, validation, and “advocacy.” They believe that focusing on the patient’s responsibility for navigating the outside world is “blaming the victim.”
Unfortunately, advocacy by itself isn’t therapeutic. Validation and support don’t lead to change.
Advocacy in therapy — more accurately, advocacy instead of therapy — doesn’t directly improve the noxious environment either. Framing the patient’s distress as a struggle against “oppression” draws an oversimplified battle line, with patient and therapist comfortably on the same side. It promotes a primitive fight-or-flight duality instead of creative, nuanced alternatives. This false simplification may make both parties feel better for a time. At best it may inspire activism, which may help the patient feel better indirectly, depending on the presenting complaint.
What political advocacy trades away
Of course, spurring political activism is not the purpose of psychotherapy. Psychotherapy is a treatment, not a pep talk or political rally. Therapy isn’t designed to make the world less harsh or more loving. As the old joke says, the lightbulb has to want to change.
In addition, much is traded away when political advocacy colors treatment. It’s no secret that most therapists are on the liberal side of the political spectrum. Yet politically conservative patients may badly need a safe place to talk — not a lecture. Even patients who mostly share their therapists’ political outlook may have mixed feelings, or be of two minds, about social issues.
Fundamentally, political advocacy violates the precept of therapeutic neutrality. In Freud’s original formulation, therapeutic neutrality meant not siding with one aspect of the patient’s psyche over another. No favoring the superego over the id, for example. A more modern way of saying this is that it doesn’t help for the therapist to weigh in on a conflict the patient is struggling with. Casting a vote for one side or the other won’t resolve the conflict. And let’s be clear: patients who are sufficiently troubled by social injustice to seek therapy have intrapsychic conflicts that amplify the injustices they face. No one comes to therapy for problems they can figure out for themselves.
The fundamental dialectic of psychotherapy
Marsha Linehan, the founder of dialectical behavior therapy (DBT), recognized back in the 1970s that neither blaming patients nor completely absolving them is helpful. Patients can learn to accept themselves, yet they need to change too. This apparent paradox is the “dialectic” in DBT’s name.
As I’ve written elsewhere, this dialectic of self-acceptance and change exists in all psychotherapy, not just DBT. That’s why most therapists stake out a middle ground that recognizes real-life hardships and tragedies, as well as the reality that psychotherapy is for personal, not social, change. Unfortunately, therapists who primarily see themselves as advocates for their patients conflate the political factors surrounding therapy with a false need to be political IN therapy. In doing so, they trade away the value of psychotherapy as an avenue for personal insight and development.
Working with people we disagree with
Needless to say, not all therapists and patients can work with each other. A gleefully misogynist or racist patient may stir up such intense anger in liberal therapists that they cannot work with that person. Conversely, a patient who repeatedly intones progressive talking points may anger centrist or conservative therapists. Therapists are human, and there are limits to what any of us can tolerate.
These limits should be wide, though. Just as surgeons must tolerate the sight of blood, and dermatologists cannot recoil from disfigured skin, therapists must work with personalities and viewpoints we find offensive. (Not the converse: patients need not put up with therapists who share strong, potentially offensive viewpoints. That’s one reason for therapists to tone it down — not be a “blank slate,” just leave enough room for the patient to feel comfortable and safe.)
A strong working alliance does not require political agreement. Indeed, if political talk serves a defensive function, e.g., externalization, the therapist’s job is to help the patient recognize that dynamic and look beneath and beyond it. In that sense, psychotherapy may be more effective when patient and therapist disagree somewhat politically, lest they unwittingly collude in defensive avoidance.
Image courtesy of vectorolie at FreeDigitalPhotos.net
October 23rd, 2023
In January 2021, I described my search for a HIPAA-compliant email provider for my practice, and reviewed several options. In the end I chose Hushmail for Healthcare. It was, and is, a good service: thoughtfully featured, reasonably priced (with minor changes since then), and fast support when needed. But the truth is, I didn’t stay with Hushmail.
This is the continuing saga of my search for secure email and online forms for my practice. And here’s the punchline up front: I haven’t found a service that provides all I want. Lately I’ve cobbled together two competing services that “kind of” work in combination. If anyone reading this happens to work at one of these companies and wants to please a customer like me, please take note.
The need
As I wrote in 2021, regular email is not in compliance with HIPAA, the longstanding federal law that governs the confidentiality and “portability” of medical information. Along with many other provisions, HIPAA has rules for maintaining the security of electronic medical data, and the transfer of protected health information from one place to another.
Small private practices like mine sometimes ignore these rules. I had used Google Calendar for patient scheduling for years, and with the start of the Covid pandemic, I started exchanging email with patients. Neither Google Calendar nor regular email is secure or HIPAA-compliant. But plain email is the easiest option for quick doctor-patient communication (except perhaps for texting, which isn’t HIPAA-compliant either). It’s a no-brainer for doctors and patients alike.
However, doctors and other healthcare providers need to take our fiduciary responsibility seriously. The easiest and most convenient options aren’t always, or even usually, the best. This misguided tradeoff crops up everywhere now. For example, many health care startups cut corners clinically to make their services cheaper or “frictionless.” Medical ethics are a higher standard than business ethics, and as a profession we should resist the seductions of lower standards.
As my use of email expanded, I grew troubled by the hypocrisy of writing and teaching about medical and psychiatric ethics, while engaging in unethical practices myself. During the height of the pandemic, when I was working exclusively online, I realized I needed HIPAA-compliant email, HIPAA-compliant online forms for initial inquiries by patients and my short intake questionnaire, and a HIPAA-compliant alternative to Google Calendar. That’s what prompted my initial search.
Hushmail’s tragic flaws
At the time I signed up, Hushmail offered two secure, customizable forms along with email and 10 Gb of storage, all for about $100/year. There was no calendar option, but it otherwise seemed to fill my needs, and the price was right.
The forms were great. The email proved problematic, for two reasons I hadn’t anticipated. First, patients didn’t use it. Per Hushmail’s recommendation, I created a dedicated email address in my website domain stevenreidbordmd.com, to be used solely for Hushmail. But as soon as I started sending secure webmail using that address, patients would use the address to send me regular, un-secured email. I was constantly asking patients not to contact me that way.
The bigger problem was passwords. When non-Hushmail users, i.e., all of my patients, received their first secure message from me, Hushmail asked them to set a personal password to decrypt that message, and all subsequent messages. I didn’t know their passwords. So every month, I’d hear from patients, usually by plaintext email, that they forgot or misplaced their passwords, and couldn’t read their billing statements. They’d reset their passwords, and I’d have to re-send their statements. Since their new passwords wouldn’t open any old messages, sometimes I needed to re-send several documents.
Back on the search
After about two years of this, in late 2022 I got fed up and looked again at my options. This time I was drawn to Proton, largely because it also offered an encrypted calendar. When I reviewed it in 2021, Proton either wasn’t HIPAA-compliant (no Business Associate Agreement) or I didn’t notice that it was. In any case, it was now.
Proton didn’t offer secure online forms. But it featured an ecosystem of HIPAA-compliant services — email, calendar, cloud storage, and VPN — and I figured I’d work something out. It offered 15 Gb of storage, ten customizable email addresses, the same ability to link to my custom domain that Hushmail offered, and it was only $84/yr for the “Mail Essentials” option. With some regret I bid Hushmail goodbye, and signed up with Proton.
Proton pros and cons
I finally had a secure calendar for scheduling patients. This was long overdue, works great, and feels like a necessity going forward.
Proton also solved the lost password problem. I assigned a password to each patient, and could remind them when they forgot. I gave each patient a unique 7-character password, based in part on their name. I assumed this would be more secure than one password for everyone.
On the other hand… this worked well for about six months. Unfortunately, at that point Proton suddenly required all passwords to be eight characters or more, without ever documenting any password-length requirement anywhere. I had to send out notices, further confusing many patients who didn’t quite grasp password-protected webmail in the first place. Exasperated, I gave everyone the same password.
I changed my prior Hushmail address to auto-respond with an error message, and created a new Proton email address for sending and receiving secure webmail. Proton Mail works very well, much as Hushmail did. However, patients started using my new address to send me plaintext email, just like before.
So here’s my first concrete request: Please, someone provide HIPAA-compliant email that doesn’t disclose an address that non-subscribers can use to send back plaintext email.
Then there’s the online forms. For most of the year, I left a non-secure contact form on my website, which I insisted that established patients not use. Some did anyway, of course.
I asked new patients to download my blank pdf intake form, fill it out on their computer, and return it to me using Proton Mail. This meant sending Proton Mail to them first, so they could reply to it. That way, their reply, with the attached intake sheet, was secure as well.
This was convoluted. I had to collect new patients’ email addresses in my first phone contact, before they ever saw my intake form. And I had to convey their new Proton Mail password somehow. One option was a “password hint” attached to my first Proton Mail that revealed their new password in plaintext. Another was to explain this all verbally on the phone. A third was to send them, in a separate email without encryption, a “read me” file explaining what all this was about. It was awkward at best.
Proton could streamline secure forms submissions in one of several ways. They could offer HIPAA-compliant online forms, as Hushmail and other services do. Or they could provide a “mail drop” feature allowing non-subscribers to upload files securely to a subscriber’s Proton Drive (perhaps in a quarantine folder or similar). Or, like MailHippo‘s SendSafe feature, Proton could assign each subscriber a unique URL that allows non-subscribers to securely send messages and attached files to the subscriber.
But Proton did none of these, so I had to continue searching.
Adding secure online forms
MailHippo, which I reviewed back in 2021, now offers HIPAA-compliant forms as well. They call the combination FormHippo. Per my 2021 review, I hadn’t chosen MailHippo solely due to their lack of forms. I now realize that their SendSafe feature, even without forms, would have saved me a great deal of trouble compared to the workarounds I needed with Proton.
FormHippo is $107/yr for email, up to five customizable forms, 5 Gb of email storage, message recall (not offered by the others), and the SendSafe feature. The drawbacks? No calendar, they still disclose an email address that non-subscribers can use to send plaintext email, and (sorry to say this) the hippo name and logo itself, clearly a play on “HIPAA,” which looks a bit unprofessional. Otherwise, it appears to be a very good option.
However, I’m not quite ready to abandon Proton’s ecosystem, with its calendar, cloud storage, and VPN. I’m generally happy with Proton Mail, and right now they’re rolling out a password manager, Proton Pass, that may compete favorably with the Bitwarden I currently use.
My solution so far
I simply added FormHippo to Proton. The email part is redundant, but both together still cost under $200/yr. I use FormHippo for online forms (contact and intake) and for the SendSafe URL. I ask all patients to use the SendSafe option if they ever want to contact me online. As usual, not all do. I use Proton for everything else.
(To complicate things even further, the SendSafe URL includes the login email address that the subscriber uses for MailHippo or FormHippo. I didn’t want to advertise this address, so I added yet another layer: redirection from an innocuous URL in my own domain to the SendSafe URL. Furthermore, if I want to reply online to a SendSafe message, I’m still stuck sending either MailHippo or Proton webmail, possibly to someone who doesn’t understand all this arcana. Whenever possible, I just use the phone.)
While I don’t plan to change anything for now, I consider other permutations. I could downgrade FormHippo to MailHippo (costs a little less), have patients download my intake sheet from Proton Drive, and submit it to me using SendSafe. Or I could cancel Proton, just use FormHippo, and opt for another secure calendar solution. Tutanota, for example, offers encrypted, but not HIPAA-compliant, full-featured calendars to businesses for $76/yr. (My pricing for Tutanota in 2021 must have been a misprint.)
Or I could go back to Hushmail, and tell all my patients what password to use — maybe the same universal one they now use for Proton. Hushmail also now offers a feature called a “private message center.” Information about it is scarce on their website. Apparently it allows non-subscribers to access Hushmail messages using their Google, Apple, or Microsoft credentials — instead of a password? If so, that might simplify matters too. They still don’t have a calendar though.
I confess that this journey has been challenging. It’s easy to see why many in my position don’t bother. I confess that I still send and receive texts from patients, even though I know I shouldn’t. There comes a point when you do what you reasonably can, and then don’t sweat it anymore. I’m about at that point, but still open to suggestions and comments. Let me know how you (or your psychiatrist/therapist) handles these challenges, and thanks for reading.
April 23rd, 2023
Currently, therapy apps featuring a nonhuman “therapist” aim fairly low at best, and at worst willfully mislead the public. However, the advent of large language models (LLMs) such as ChatGPT-4 brings exciting potential for genuine depth psychotherapy delivered by AI — and many challenges and potential pitfalls as well.
Since “therapy” has no precise definition, marketers apply the term to any product, digital or not, that arguably helps a user’s emotional state: encouragement by text, formulaic cognitive homework, brief meditative interludes, and so on. The semantic ruse is that the vague term “therapy” often stands in for psychotherapy, a word with a good deal more precision.
The current state of AI therapy
Unlike affirmations, inspirational poems, and nonspecific relaxation exercises, psychotherapy is a treatment designed to alleviate specific emotional problems. Professional psychotherapists adapt general principles and strategies to a specific patient, and alter their approach based on their patient’s real time response.
Some therapy apps can now simulate this, at least in part. However, even the most advanced and nuanced are quite rigid compared to a skilled human therapist. No current app escapes the orthodoxy of its programmers: users deal with a procrustean bed that either fits and helps, or painfully doesn’t.
More fundamentally, apps that emulate psychotherapy limit themselves to cognitive behavioral therapy (CBT) and its offshoots. This has been a pragmatic choice — notwithstanding marketing that falsely implies CBT is the best mental health treatment for almost everything. It’s simply easier to operationalize and program CBT compared to other types of psychotherapy. Current computer programs respond to users by following instructions in flowcharts and decision trees, sometimes with fuzzy logic to make the output somewhat less predictable. Semi-random word substitutions, along with jokes and other human speech markers, can make the dialog more lifelike.
CBT helps many people with relatively concrete emotional symptoms such as depressed mood, certain types of anxiety, and insomnia. As CBT therapy apps continue to improve, they may eventually rival treatment conducted by skilled human CBT psychotherapists. If I were a CBT therapist, I’d be anxious over the prospect that AI could replace me in the next five to ten years.
Why we need more
Even when conducted by skilled humans, CBT is not well suited for obscure emotional distress or dissatisfaction, unwitting self-defeating behavior or attitudes, or recurrent dysfunctional relationships. Psychotherapy of “depth, insight, and relationship,” in particular the psychodynamic psychotherapy that began with Freud but evolved over the past century with refinements in theory and technique, addresses these more pervasive yet subtle struggles.
Such therapy lacks CBT’s reputation as “evidence based treatment,” but this is a false narrative. Empirical research documents this evidence, and in fact casts doubt on the value of “evidence based” claims to differentiate schools of mainstream psychotherapy. Unfortunately, dynamic psychotherapy is by nature time-intensive and therefore expensive, and therapists are always scarce.
To date, AI researchers and developers have not attempted to tackle psychodynamic psychotherapy. It’s a tough area. As Freud famously observed, such therapy is like chess: “… only the opening and closing moves of the game admit of exhaustive systematic description… the endless variety of the moves which develop from the opening defies description….” Moreover, this type of treatment relies on transference and countertransference, carefully timed interventions, inferences about inner states, and much else that standard programming technique cannot capture.
Large language models
Recently released large language models (LLMs) appear to overcome some of these stumbling blocks. ChatGPT, a product of OpenAI, responds to typed questions in nuanced ways that are not “canned.” OpenAI trained the model with all of the psychological theory on the internet (and much, much else). People are already using ChatGPT as a makeshift therapist. Thanks to its vast training set, and leaving aside its occasional “hallucination” of false information, ChatGPT is likely better than most other sources at serving up regurgitated mental health tips and advice.
However, to tap the real magic of LLMs, “fine tuning” is key. This alters the LLM such that certain types of responses are favored, and others are disfavored. Most simply, developers could fine-tune a copy of ChatGPT to answer questions in the style of a well-known psychotherapist, or of a named school of psychotherapy. Users would not have to specify this qualification each time in the input.
Surprising capabilities of LLMs
Of course, answering questions is not the main job of the dynamic psychotherapist. Here’s where it gets interesting. In an exhaustive review of early experiments with ChatGPT-4, the latest iteration, a Microsoft research team found the model possessed surprising emergent properties. As documented in their paper, ChatGPT-4 offers plausible accounts of internal mental states to help explain human behavior. It can predict the likely emotional and behavioral response of a described person to its own output. It evidences “theory of mind.”
Given the above, ChatGPT-4 should be capable of “educated guesses” about the functional and emotional role it plays for the user, i.e., transference, as well as the range of emotions a human (or a human with a particular personality) might feel in its position. That is, countertransference of a sort.
Developers could fine-tune ChatGPT-4 and its successors to emphasize “theory of mind” and transference-countertransference aspects, as well as other traits and emphases of the psychodynamic psychotherapist.
Just a machine?
Hold on, I hear you say. This is just a machine, a fancy program. People can’t form therapeutic relationships with non-humans.
They can and do. In fact, it’s remarkable how readily most folks anthropomorphize their dogs, cats, robot vacuums, and the primitive therapy chatbots now in use. Empathy is imagined on very little evidence. A sophisticated AI therapist would turn this bug of human nature into a feature.
Ok, what are the challenges?
Many challenges await — and not being an AI expert, I can’t say whether these are easily solved, difficult, or impossible. Here is a far from exhaustive list.
First and perhaps easiest, security and privacy need to be built in from the start. To protect personal health information (PHI), developers may need to supply each user with a separate instance of the AI disconnected from the internet. (Current LLMs function independently of the internet, although some in development are online, in order to download and incorporate up-to-date information, access other resources, etc.)
Second, the usual question-and-answer format of interacting with ChatGPT needs to be reversed. In psychotherapy, it’s the therapist who mostly asks the questions. Indeed, an LLM fine-tuned for dynamic psychotherapy would not answer many questions put to it.
Third is the vexing issue of timing interventions. While an LLM could be fine-tuned to stay on task, and to offer standard psychotherapy interventions like observations, clarifications, and interpretations, it may not be possible using current models to programmatically control when it offers them. From what I’ve read, this may be a major hurdle.
Fourth, measures of client progress need to be part of the model. Psychodynamic therapy isn’t only concerned with symptomatic improvement of mood or anxiety; it also tracks more abstract gauges of well-being such as the ability to love, work, and play; stress tolerance; accurate self-assessment, and so on. Much of the training of depth psychotherapists is devoted to recognizing these “soft signs” of mental health, which defy self-report rating scales and other concrete measures.
Technical point: A real psychotherapy app would include significant conventional programming, with ChatGPT invoked through an application programming interface (API). ChatGPT APIs are already available and in use. The regular part of the app might handle some of the challenges above.
Where would this leave us?
Even if all of this and much else were handled well, many depth psychotherapists would object that there is no “human connection” with AI. True empathy would still be missing.
How much this matters would be, to some extent, a testable question. As noted above, the inability of current therapy chatbots to feel empathy doesn’t render them useless. We should remember that even if AI imperfectly emulates human-led psychodynamic therapy, it could still prove hugely beneficial for the many who have no access to the real thing, and are not well served by treatments limited to concrete symptoms.
My sense is that creating a useful psychodynamic psychotherapist using LLM technology would be a serious challenge, but may be possible. Moreover, the mere effort, even if unsuccessful, would help to clarify some of our thinking about this type of psychotherapy. In the best case, serious AI psychotherapy may soothe troubled souls the same way human therapists do: by fostering emotional insight, and through the healing nature of the relationship itself.
Image by Eric Blanton from Pixabay
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