Category: Treatment Planning

Should Transgender Youth Care be Guided by Beliefs or Science?

Posted on by Psychotherapy.net Team

Introduction

The current American approach to transgender-identified youth and adults is strongly affirmative. Many professional organizations in the United States have endorsed the safety and efficacy of social transition, puberty-blocking hormones, cross-sex hormones, and breast, genital, and facial surgeries as the ideal treatment of gender dysphoria.
 

These prestigious decade-old endorsements have led to the development of gender specialists in over 70 US clinics where children, adolescents, and younger and older adults are seen. It also has led to affirmative care being taught in medical schools, residency training programs, and various mental health continuing educational programs. For half a century, WPATH has been the key nongovernmental organization that has gathered specialists, provided courses that promulgate clinical principles, and published standards of care. WPATH represents itself as an advocacy, policy, and scientific organization.

Its membership recognizes a great need for social change as discrimination in housing, employment, health care, intrafamilial and peer relationships, and incarceration are significant cultural sources of stress for the transgendered. WPATH considers its recommendations to be scientific, even though its author-committees recognize a need for improved scrutiny of outcomes of social, medical, and surgical interventions. While it recognizes that the quality of supportive evidence is objectively low, nonetheless, it treats affirmative care as a settled scientific matter. DSM-5-TR and ICD-11 diagnostic criteria exist, elective treatment sequences have been defined, and many clinicians and patients consider affirmative care to be life-enhancing and sometimes lifesaving.  


Affirmative care, however, is not a scientifically settled matter. There is much justifiable ferment. Affirmative care is far more fraught and uncertain than WPATH and professional associations have suggested. (1-3) It is a paradox for WPATH to portray itself as a trustworthy authoritative advocacy, policy, and scientific organization in the face of uncertainties about long-term treatment outcomes, the unexplained dramatic explosive incidence of new gender identities, and the increasing recognition of de-transition.

There is an ongoing culture war within the US about the treatment of transgender youth who are uncomfortable with their bodies. (4) The political aspect of this culture war addresses transgender treatments as a conflict between those who support and those who oppose the civil rights of LGBTQI+ individuals. Those who question the wisdom of affirmative care are described as “anti-trans.” A medical perspective begins with a different question: Is the scientific basis for affirmative care sufficiently established? If the answers are either no or uncertain, three other questions follow.  

  • Can gender specialists separate their beliefs from what is scientifically known about etiology, incidence, psychopathology, and the long-term benefits and harms of affirmative interventions?  
  • Can these specialists provide parents and patients with the legal and ethical requirements for informed consent? (5)    
  • Can high-quality research be designed and funded to answer the current relevant clinical uncertainties?  


Usually when health is the topic the medical profession leads the way, relying first on rigorous science, and second on the values of individual patients and their families. In the arena of trans care, however, values have historically played a more important role than science. This may be summarized as eminence-based or fashion-based medicine dominating over evidence-based medicine. As has been seen with the COVID vaccine, mask mandates, the opioid epidemic, and the FDA approval of a drug for Alzheimer’s disease, trust in the medical profession is far from universal. Consequently, what individual doctors, gender care clinics, professional societies, and mental health professionals may have to say about the ideal care of trans persons may not be the most powerful force governing social policy.    


Forces Shaping Attitudes About Transgender Care

Transgender phenomena elicit intense feelings among laypersons and professionals. Such passion, which is destructive to objective scientific appraisal, derives from many personal sources. While numerous factors influence attitudes toward transgender care, their confluence makes it difficult to judge their relative contributions to how individuals and institutions regard trans healthcare.  

There are five universal potential influences.      

1. Fascination with sex change. The intriguing question, “Can sex be changed?” has long been explored in the arts, where men and women have for centuries been presented as the opposite sex in humor, drama, dance, opera, drag, and popular music. Today, it is better understood that in a basic biological sense, sex cannot be changed, but gender presentation can, with or without medical assistance. 

2. Political sensibilities. The Left may consider transgenderism the courageous pursuit of self-expression, a civil right, a movement to improve diversity in all walks of life, and a praiseworthy social movement to eliminate discrimination. Their political values lead them to view studies and clinical services with trust. The Right, on the other hand, may consider transgenderism morally wrong, threatening to societal health, and dangerous to the health and well-being of individuals and families. These assumptions lead to a skeptical approach to studies and clinical services.

3. Religious sensibilities. These value-laden thought patterns derive from theological assumptions. They may resemble the Right or the Left. In the United States, the most vocal religious institutions on this topic lean to the political Right. 

4. Sexual orientation sensibilities. Membership in the heteronormative or sexual minority communities often generates opposite responses — the former may have initial unease with, and the latter, initial comfort with trans phenomena. One’s sexual orientation, per se, does not guarantee a particular attitude any more than one’s political or religious affiliations do. However, many of the leaders who advocate trans care identify as a sexual minority.

5. Intuitive age-related sensibilities. Intuitive sensibilities are best reflected through age. Younger and older generations have different life experiences with which to be intuitive regarding attitudes toward the transgender experience. The very existence of sexual minority communities and their entitlement to civil rights are far more visible today than was the case when older persons were growing up. These generational differences reach into each group’s system of values. 

There are four influences that are unique to professionals.  

6.Personal clinical experience. The 7th edition of WPATH’s Standards of Care (SOC) downgraded the importance of a comprehensive assessment of psychiatric co-morbidities in determining the next step. 6 The process of evaluation was then pejoratively referred to as gatekeeping. Prior to 2012, adults who immediately wanted hormones or surgery were often impatient, demanding, rude or dishonest about their histories. With the 2012 guidance, adults and older adolescents were assumed to know best what should be done. Respect for Patient Autonomy became the primary ethical principle to follow. The frequency of unpleasant clinical experiences dramatically diminished. When professionals experience unpleasant patients, those with conspicuous emotional impairments, or those who deteriorate with hormonal treatment, they are more likely to be avoidant of future encounters. Positive experiences with appreciative patients and families yield more willingness to engage. 

7. Knowledge of clinical reports from clinical innovators. Positive outcome studies of transgender treatments typically consist of retrospective case series without control groups and without predetermined measurement instruments. Such outcome reports are numerous for each intervention. Positive results tend to be more often published than negative or uncertain outcomes. The most influential studies for minors were published in 2011 and 2014, and while they too lacked a control group, they were interpreted as establishing the concept that selected prepubertal cross-gender identified children could benefit from affirmative social, endocrine, and surgical care. (7),8 

Clinicians cannot be expected to keep up with the burgeoning literature; they trust what they read, heard about, or were taught. Such learning reflects a chain of trust that is basic to all medical education. It has become apparent that the chain of trust is not necessarily trustworthy, as positive studies are published in peer-reviewed journals only to have their conclusions criticized by knowledgeable academics. Once clinicians begin to facilitate patients’ transitions based on the studies they have seen, they believe they are facilitating happy, successful, productive lives even without having the reassuring follow-up information to verify their beliefs.

8. Scientific studies. Groups of studies demonstrate patterns that individual studies do not. Scientific data are widely assumed to dominate institutional policy. This is not necessarily so, however. For example, high desistance rates in trans children have been demonstrated in 11 of 11 studies, (9) but a committee of pediatricians created a policy of supporting the transition of grade school children. (10) As a result of these often-conflicting processes and sources of data, comprehensive evaluation and psychotherapy rather than affirmative care are increasingly being recommended

9. Source of income. With 70+ clinics in the United States, with many individuals in private practice who practice affirmative therapies, and with special units within prisons to support trans inmates, the attitudes of new-to-this-arena clinicians may be quickly determined by their work environment. In these settings, disapproval of affirmative care, which may grow with experience, as it did for many psychologists at the Tavistock Clinic, means resignation or job loss. 


Sources of Controversy about Affirmative Care

1. Morality — Conservative citizens, religious denominations, politicians at local, state, and federal levels, and some gay, lesbian, and feminist groups view affirmative care as dangerous. They ask, “What are we doing to these young people? What will be the outcome for them and their families? Do doctors really know what is best for my son or daughter? Why is it acceptable to sterilize young people? Why is the suicide rate high after completion of medical and surgical interventions?” Such questions burrow down into moral values.

Some religious groups assert that since God made male and female, this provides fundamental guidance to decision-making. However, because these groups have historically been similarly against homosexual lives, the power of this theological assumption is politically diminished for many others.

Some gay and lesbian organizations see affirmative care of feminine boys and tomboys as an attempt to eliminate gay and lesbian people. Almost all groups recognize that cross-gender identification is nothing new. What is new is its dramatically increased incidence and Medicine’s response to it.  
 

2. Questions Emanating from Medical Ethical Concerns

  • Are children and adolescent patients experienced enough, cognitively mature enough, to make life-altering decisions that will predispose them to known challenges such as sterility, sexual dysfunction, decades-long medical care, discrimination, and loneliness (11, 12)  
  • Do their frequent co-existing psychiatric diagnoses further impair their ability to thoughtfully consider the consequences of each of the steps of affirmative care? 
  • Are affirmative professionals knowledgeable about the limitations of their recommendations? 
  • Do they know the inadequacies of the outcome data supporting the policies of socialization of children and endocrine and surgical interventions with adolescents?
  • Do they know the fate of most patients given hormones a few years after they age out of pediatric endocrinology?
  • Are they aware of the rates of complications, physiological consequences, long term unhappiness after the surgical procedures that they recommend?
  • Are parents sufficiently informed about the limitations of outcome data?
  • Are they told of Sweden’s, Finland’s, UK’s, and France’s shifts towards psychotherapeutic-first interventions?
  • Are they informed about the social, economic, vocational, physical, and mental health problems of transgendered adults? 
  • Are they told about detransition following hormonal and surgical treatments? 
  • Are they told about the elevated suicide rates after surgical treatment of adults? 

3. Confirmation bias — When defending a particular position, authors tend to quote studies supporting their position and ignore contrary findings or glibly dismiss them as methodologically unsound. This confirmation bias creates important scientific concerns on both sides of the debate. Science advances by defining controversy and designing a study that may better answer a specific question. Independent reviews have concluded that the evidence is not convincing that puberty blockers and cross-sex hormone administration lastingly improve mental health, decrease suicidal ideation, or eliminate gender dysphoria. (13) 

The Endocrine Society acknowledges a low level or very low level of supportive evidence. Advocates, however, portray certainty that science has already demonstrated these lasting benefits without significant harm. When they list supportive studies there is no mention of the published criticisms of them. A scientific review is characterized by balance; it is not performed only by those who deliver the treatment. (14,15) Trustworthy reviews point out the limitations of studies and ideally suggest a study design to answer the specific question.  

4. Political — Nowhere in Medicine has free speech been as limited as it has been in the trans arena. Skeptics are being institutionally suppressed. Critical letters to the editor in journals that published affirmative data are refused publication, symposia submitted for presentation at national meetings are rejected, scheduled lectures are canceled, and pressure has been exerted to get respected academics fired. A notable exception to this pattern occurred when a paper investigating the long-term mental health outcomes of trans adults (a basic unanswered question) was published in the American Journal of Psychiatry.

It, of course, had undergone a peer review process by experts in gender care. When the authors asserted in their online publication that their data supported increased access to surgeries, the editor received seven critical letters. In response, Dr. Kalin had two independent statisticians review the work. They agreed with the twelve authors of these letters to the editor that the data did not demonstrate improvement in mental health. The editor published the original article, the seven letters, and the authors’ response. The authors retracted their conclusions. (15,16) When critical letters have been sent to other journals, they have been rejected. As a result, they are published in separate journals.

This makes it more difficult for clinician readers of the original journal to know about the critique. Unless published with open access, the original flawed article’s limitations are difficult to access in another journal. A significant paywall is often encountered to obtain articles in journals to which the professional does not subscribe. Given the well-known attacks on those who question the prevailing wisdom of affirmative care, it is not surprising that many mental health professionals avoid working with these individuals and their families for fear of being labeled as anti-trans, transphobic, or conversion therapists.  
 

5. Familial — The parents, siblings, and extended family members, each of whom have different relationships and responsibilities for the trans-declared person, typically have intense feelings about their relative’s gender change. Family members’ affects, attitudes, and behaviors derive from one or more of the five sources discussed above but take on a new poignancy. While parents are the only ones that professionals deal with, the intrafamilial ramifications affect everyone.

Parents have realistic, reasonable concerns. What will gender change mean for my child’s developmental future physical, social, and mental health? Their assumptions that the outcome will be negative often create an acute depression. This intensifies when their expectation of informing the mental health professional (MHP) about the child’s development, personality, and previous challenges.

Many parents are distressed when the MHP seems far more interested in making the diagnosis and declaring their belief in affirmative care. Parents who have not previously seen behavioral evidence or heard expressions of cross-gender identifications prior to puberty want this new identity to be taken away. Other concerns emerge over time. How will the gender change impact siblings and grandparents? How to discuss it with others? How to ensure we don’t lose our relationship? What to do with one’s anger at the child and one’s guilt of not seeing this earlier? How to find an MHP who will not quickly affirm but is willing to spend time understanding the family situation? 

Parents who are not supportive are often described as transphobic by their child. They often learn this accusation on the Internet. A more accurate and kinder description of these parents might be trans-wary or trans-opposed. When transphobic is used, it induces some adolescent patients to behave hatefully toward their parents. While the medical profession focuses on the patient, parents are immersed in a dramatic conflict within the home. Gender specialists only gradually become aware of this when they follow the family. This is one of the reasons for an extended evaluation process. (8, 17)   


Problems Facing Transgendered Persons

There is agreement about the challenges that transgender adults as a group are facing. The medical profession has been repeatedly told that the explanations for the poor state of physical and mental health and the diverse health disparities are minority stress, discrimination, and barriers to health care. (18) There is no mention in such discussions of the possibility that the mental health of a trans person may be intrinsically compromised even though many studies have shown the poor mental health of children before the diagnosis of gender dysphoria is made. (19) 

Rather, discrimination experienced by some in healthcare settings and fear of mistreatment in health facilities by others are emphasized. Higher rates of cardiovascular diseases, obesity, cancer, sexually transmitted diseases including HIV, syphilis, hepatitis C, and papillomavirus, and shorter life spans have been noted. Higher rates of depression, anxiety, substance abuse, suicide attempts, and suicide, (20) as well as seeking psychiatric services have been documented. 21 Gender minorities are more likely to live in poverty, be unemployed, be victimized by domestic partners, be homeless at some time, and be on disability. (20)   


Nowhere in these well-documented patterns is the suggestion that what is known about adult trans populations should create more caution about affirmative care for minors. Rather, many articles urge better medical education to promote affirmative care for young persons, (20, 22) or for medical institutions to fight against the legislative forces that are attempting to limit affirmative care to minors. (23, 24) These authors ignore the more cautious approaches developing in Europe.  
 

Affirmative Care Assumptions

The following concepts, sometimes articulated as principles of care, (6) enable the conviction that more, rather than less, affirmative care is indicated. When these ideas are presented as unproven, those who practice or support affirmative care of youth

A Behavior Treatment Plan as a Psychological MRI

Posted on by Psychotherapy.net Team

As a psychotherapist providing services in nursing facilities, I am accustomed to using a variety of forms, including initial assessment, progress notes, and treatment plans. I have come to appreciate that the behavioral treatment plan may be the most powerful, yet the most overlooked or avoided, clinical form.

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My clinical task is to provide direct assessment and treatment services to nursing facility residents. Yet I also have an obligation to offer insights that help the facility caregivers to better understand and more effectively manage the sometimes-troubling behaviors demonstrated by that resident. Direct care staff persons at the nursing facility might observe only the most obvious and observable element of the resident’s behavior—the unkempt appearance, the irritable defensiveness, the argumentative refusals of care, the unwelcome sexual remarks, the tearfulness, the yelling, the social avoidance, or the aggressive and abusive language aimed at them. In response, the caregiver may react in a personal manner, with expressions of indignation or criticism, or even patronizing efforts at persuasion. What I have often seen lacking is a keen awareness of the inner meanings and motives behind those behaviors; the ways they might reflect or represent symptoms of varied medical and psychological conditions and the ways that the caregivers’ responses might increase or decrease the intensity and duration of those symptomatic behaviors.

Nurses and clinical aides might occasionally notice the assessment and progress notes that I and fellow clinicians generate but at the same time never read those documents. However, the nurse or aide might not readily gain a new understanding of the resident even if they did read those forms. A behavior treatment plan, though, can provide a window into the psychological nuances that illuminate and explain the actions of the resident. The behavior treatment plan can be like a psychological MRI that provides an inside view of factors influencing a resident’s behavior.

A behavior treatment plan is effective because it does not simply get written and quietly entered in the chart. It requires review, explanation, and education so the facility staff persons can understand and implement the plan. Brief staff in-service training follows the writing of a plan so that it can be introduced and clarified. Those trainings allow for discussions that may be a first opportunity for the staff persons to readily understand the psychiatric diagnoses of the residents and how their psychiatric symptoms are behaviorally manifested.

Resident: Leslie (Identifying information has been altered from the example below.)

Diagnosis: 295.70 Schizoaffective Disorder, Bipolar Type; Epilepsy; Developmental Disability due to Fetal Alcohol Syndrome; and PTSD Associated with Childhood Sexual Abuse.

Presenting Problem/Target Behavior: Leslie demonstrates unstable affect with frequent bouts of crying or expressions of anger; fluctuating levels of alertness and mental clarity; and apparent passive-aggressive and/or attention-seeking behaviors such as self-admittedly putting herself on the floor and crawling towards the bathroom to express her anger over perceived delay in staff response to her need to use the toilet. In general, Leslie sometimes displays a child-like manner with inconsistent cooperation with care and treatment and a tendency to over-dramatize daily upsets in ways that elicit comforting and extra involvement of staff persons.

Description of Resident & History of Problem: Leslie is a 51-year-old single woman with epilepsy and major mental illness, developmental problems, and past trauma. Considering the above diagnoses, it is to be anticipated that she might demonstrate problems with her social behaviors and critical thinking skills. It is important to remember that her actions reflect serious problems with brain development and functioning and do not simply represent “bad behavior.” Behavior and cognition can be significantly affected for persons with epilepsy as well as by unwanted effects of antiepileptic drugs. Also, a person with the above diagnoses can be burdened by painful feelings of social stigma and by difficulties establishing and sustaining trusting relationships with others.

Clinical Assessment of Behavior & Resident: Leslie experienced developmental disability due to effects of Fetal Alcohol Syndrome. She later developed Schizoaffective Disorder, Bipolar Type. Her psychosocial development was further undermined by sexual abuse by her father, the forced termination of a resulting pregnancy, and associated traumatic consequences.

It is well known that consequent to long-term institutional care, some persons can develop dysfunctional patterns of behavior referred to as “learned helplessness.” These factors provide a background context in which to view and understand the behavior problems demonstrated by Leslie. The resident is not to be blamed or negatively judged for having acquired a child-like, passive-aggressive, and dependent style of coping and problem solving. At the same time, Leslie cannot be expected to simply snap out of it and immediately display a fully adaptive adult style of coping with daily stresses. Over time and with consistent encouragement and reinforcement, Leslie can be helped to learn and practice dealing with problems and expressing emotions in more reasonable and mature and independent ways. Presently, she is effective in soliciting emotional support and the close and helpful attentions of others by displaying emotional distress (tears or anger) or by taking risks, such as placing herself on the floor in defiance, that draw others closer to her.

Behavioral Interventions: The main purpose or intent of this behavior plan is to foster, encourage, and reward small progressive steps towards more self-reliant adult ways of meeting her needs. Leslie directly contributed to the development of this behavior plan. I shared with her the feedback and observations and stated concerns of staff persons and elicited from Leslie her own ideas for ways to address those concerns.

Leslie offered the following points: “I will not express anger by doing unsafe things like putting myself on the floor; I learned my lesson good.” “I will try to show good emotional self-control.” In the event that she was to again lower herself to the floor, Leslie suggested that staff persons should stand safely nearby and “let me try to pull myself up.” Leslie said, “Let me do more on my own.” “If I am crying or angry, let me alone for a while and I’ll calm myself down.”

Staff persons interacting with Leslie should keep in mind the general principle of promoting her growing maturity and improved ability to soothe her own upset emotions and to work constructively and cooperatively with staff to meet her needs. Avoid correcting her with scolding or display of annoyance, as that could trigger withdrawal or passive-aggression or tearful emotional collapse. Invite Leslie to brainstorm ideas for ways to correct problems, resolve dissatisfactions, compromise with others, or be more compliant with needed care and treatment. Encourage Leslie to take deep breaths and to collect herself emotionally before engaging in such brainstorming or came back later if she needs more time to soothe her emotions. Expect Leslie to adopt a more measured and sensible sets of problem-solving skills, but do not become frustrated or annoyed by the unavoidable delays and lapses she will continue to display along the way. Use your words and actions as ways to invite her into more mutually rewarding adult ways of coping. Guide her toward the acquisition of genuinely adult skills and viewpoints while remaining patiently aware of the deep and longstanding obstacles that interfere with her having already learned those methods.

***

I met with the unit nurses and aides to review and discuss this treatment plan. Some had not been aware of Leslie’s history of Fetal Alcohol Syndrome, of her hearing voices, or of her history of sexual assault. Some were surprised by the discussion of epilepsy and psychological and behavioral symptoms. Yet a renewed sense of compassion and of helpful mission were awakened by the conversation about ways they might aid her development—even during their ordinary and routine tasks. The workers now applied the new insights and asked thoughtful questions about her specific behaviors. They felt less reactive in a personalized sense, and better prepared to shape their actions so as to improve hers.

Treating the Compulsive Personality: Transforming Poison into Medicine

Posted on by rezendevknowfully.com

One summer during my analytic training, I committed myself to study, outline, and completely internalize Nancy McWilliams’s Psychoanalytic Diagnosis (1994). The idea that you could be more effective with clients by understanding their specific patterns ran contrary to the anti-diagnosis attitude at my training institute. But it appealed to my eagerness to be helpful.

Not long after I began, I recognized myself in the chapter on the obsessive-compulsive personality. While I didn’t meet the DSM-5 criteria for obsessive-compulsive personality disorder (OCPD), I certainly had my compulsive traits: perfectionism, over-working, and planning, just to name the obvious. McWilliams’ description elucidated who I could have become, had I not had a supportive family and lots of analysis to rein in those tendencies.

But this wasn’t just personal or theoretical. I recognized the collection of traits found in the personality style in my many driven, Type A, and perfectionistic clients working in law, finance, and publishing in work-crazed midtown Manhattan. And I saw the suffering it caused.

The Unrecognized Stepchild of Personality Disorders

Captivated by the subject, I eventually got involved in some online OCPD support groups. There, I read many stories of people who thought they had OCD for years before finally realizing that their entire personality was characterized by compulsive tendencies. They had known that their struggles weren’t just with specific obsessions and compulsions, but that was the only diagnosis they were aware of that was even close to describing them. And in many cases, OCD was the diagnosis a clinician had given them.

This pattern of misdiagnosis became even clearer once I began receiving comments and emails from people reading my new blog, The Healthy Compulsive Project, and my book, The Healthy Compulsive.

While OCPD is one of the most frequently occurring personality disorders of the ten listed in the DSM, it is under-recognized and probably underdiagnosed (Koutoufa & Furnman, 2014). Far too often, it’s confused with OCD by both the public and clinicians. One study indicates that the lack of recognition of the condition leads to a lack of empathy for it (McIntosh & Paulson, 2019). And far more people suffer from obsessive-compulsive personality traits than those who meet the full criteria.

It doesn’t help that it’s ego syntonic not just for the sufferer, but to some extent for our culture as well. Capitalism doesn’t care if you work too hard. According to psychologist and researcher Anthony Pinto (2016), there is no empirically validated gold standard treatment for OCPD. I suspect that this is a function both of our tolerance of it and of the difficulty in treating it.

What’s the Meaning of This?

As I filtered all of this through my training as a Jungian analyst, my curiosity about the underlying meaning of the disorder was piqued. Jung emphasized the importance of asking what symptoms and neuroses were for. What potentially adaptive purpose did symptoms serve in the patient’s life, or for humankind at large? Could there be meaning under something so destructive? Was there some underlying attempt to move toward individuation gone awry?

Looking up the etymology underlying the word “compulsion,” I realized that it wasn’t originally a bad thing. A compulsion is an urge that’s almost uncontrollable. A drive or force. And that’s not all bad. Many of these urges lead to creative and productive behavior. But “before I could find any possible light in the condition, I had to acknowledge how dark it could be”.

The Cost of OCPD

The more I observed the world of the obsessive-compulsive personality, the more I came to see its destructive potential. A review of OCPD by Deidrich & Voderholzer (2015) tells us that people who have OCPD often have other diagnoses as well, including anxiety, depression, substance-abuse, eating disorders, and hypochondriasis. OCPD amplifies these other conditions and makes them harder to treat. People with OCPD have higher than average rates of depression and suicide and score lower on a test called the Reasons for Living Inventory (Deidrich & Voderholzer, 2015).

Medical expenses for people with OCPD are substantially higher than those with other conditions such as depression and anxiety. And the study indicating this only included people who had sought treatment—which excludes the many with more serious cases who don’t (Deidrich & Voderholzer, 2015).

The cost for couples and families is great. People who are at the unhealthy end of the compulsive spectrum can be impossible to live with. They can become mean, bossy and critical, and their need to control often contributes to divorce. Much of the correspondence I receive is from partners of people with OCPD who are at the end of their rope, looking desperately for hope that their partner can change.

Parents with OCPD often place unreasonable demands on their children. This can interfere with developing secure attachment and may also increase the chances of a child’s developing an eating disorder.

It also causes problems in the workplace. While some compulsives are very productive, others become so perfectionistic that they can’t get anything done. Still others prevent their coworkers from getting anything done because their criticism disrupts productivity.

Similar problems happen in other organizations such as volunteer groups and religious institutions. People with compulsive tendencies often become involved in community groups, and they’re so convinced that they’re completely right, and that they should control everything, that they contribute to the deterioration of the organization, partially because others don’t want to work with them (Deidrich & Voderholzer, 2015).

Just as disturbing is knowing of the many personal, community, and cultural benefits that the condition prevents when it hijacks energy that would otherwise have led to leadership, creativity, and productivity. Compulsives can be movers and shakers, but instead they often end up being blockers and disruptors. The people who shape the world are the ones with the most determination, not the ones with the best ideas. And compulsives have lots of determination.

The Adaptive Perspective on OCPD

As I looked more deeply into the condition, I could see that the original intention beneath compulsive control is positive: compulsives are compelled to grow, lead, create, produce, protect, and repair. It seemed to me that the obsessive or compulsive personality is not fundamentally neurotic, but a set of potentially adaptive, healthy, constructive, and fulfilling characteristics that have gone into overdrive.

I’m certainly not the only one to make this observation. A dimensional perspective of personality disorders is gaining momentum (Haslam, 2003). But this viewpoint is still sorely needed for sufferers, partners, and clinicians.

Realizing that evolutionary psychology might provide an understanding of the adaptive potential of obsessive-compulsive tendencies, I contacted psychologist Steven Hertler, who has been on the front lines of thought in this area. His ideas resonated with what I had suspected about the survival benefits of obsessive-compulsive tendencies: the behavior that those genes led to made it more likely that the offspring of those with the genes would survive (Hertler, 2015). For instance, being meticulous and cautious is part of what Hertler (2015) refers to as a “slow-life strategy,” which increases the likelihood that those genes will be handed down.

Most importantly, though, a perspective which highlights the possible benefits of a compulsive personality style has significant clinical benefits. Conveying the possible advantages of this character style to clients lowers defensiveness and encourages change.

There is a wide spectrum of people with compulsive personality, with unhealthy and maladaptive on one end, and healthy and adaptive on the other end. Clients on the unhealthy end of the spectrum can be very defensive about their condition. They tend to think in black-and-white terms, good and bad, and their sense of security is dependent on believing that they are all the way on the good side. This makes it hard for them to acknowledge their condition, enter therapy, and get engaged in treatment. When they do come in, it’s usually because their partner is pressuring them, or because they have become burned-out or depressed.

If we are to help people suffering from obsessive-compulsive personality disorder, we need to find a way to get under their defenses so that they can make use of therapy. When we understand and convey that OCPD is a maladaptive version of something much more positive, we begin to forge a good working relationship.

But as therapists, we should also acknowledge that some individuals are so far to the unhealthy end of the continuum that even if they were to enter therapy, we might not be able to help them. It was important for me, at least, to be realistic, so that I didn’t set myself up to feel that I had failed if I wasn’t able to help someone.

Characteristics of the Obsessive-Compulsive Personality

The DSM-5 says that OCPD is defined by a “preoccupation with orderliness, perfectionism, and mental & interpersonal control at the expense of flexibility, openness, & efficiency” (American Psychiatric Association, 2013). It goes on to list eight criteria; since these criteria are readily available, I won’t list them here. But I do want to emphasize what the DSM-5 (2013) points out in the first criteria: people with OCPD are preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. I have found this to be a defining characteristic of people on the unhealthy end of the compulsive spectrum—they’ve lost the point of their rules and efforts to control. They’ve lost their original intention, the thing they first felt compelled to do.

I remember being struck the first time I noticed this. A female client was talking about how she had berated some people for not following the rules. It struck me that she was so adamant about the rules that she had forgotten who the rules were meant to help and protect—the very people she was berating.

One goal of treatment should be to help clients recover, or uncover for the first time, the original impulse, the deeper motivation that has compelled them. I may be biased because I practice psychodynamic treatment, but it seems to me that because OCPD affects the entire personality, psychodynamic treatment will be the most effective. I say this because cognitive and behavioral treatments are most effective for very specific issues, less so for the sort of global issues that characterize OCPD.

But those of us who work psychoanalytically may need to budge a little on maintenance of the frame, disclosure, the use of goals, and our reluctance to diagnose. Just as the saying “the only way to peace is peace” goes, “the only way to flexibility is flexibility.” We need to be mindful of our own personal need to control, and a certain rigor that our training may have encouraged: we might think or feel that we are doing the “right” thing by following the rules. But in particular aspects of the work with compulsives, we may gain more through example than through analysis.

Eight Key Points

I’ve found that there are particular themes and tasks that I usually need to work through with compulsive clients over time. I don’t believe that these are unique to OCPD, but rather that they usually require more emphasis than might with other conditions. I outline these below with the suggestion that they be used in a flexible and organic way, rather than as hard and fast steps.

In each of these steps I try to enlist clients’ adaptive compulsive characteristics to foster change.

  1. Create a narrative respecting inborn characteristics. To help compulsives diminish insecurity and develop self-acceptance, “I’ve found that it is important to create a narrative which distinguishes authentic, organic aspects of their personality” from those which were the result of their environment. Compulsives are born with traits such as perfectionism, determination, and attention to detail. They usually like constructive projects, and this can be a joint project that nurtures the working therapeutic relationship.
  2. Identify the coping strategy they adopted. If there was a poor fit between the client and his or her parents, the child may have used their inborn tendencies, such as perfectionism, drive, or self-restraint, to find favor and to feel more secure. Most unhealthy compulsives become so when their energy and talent are hijacked and enlisted to prevent feelings of shame and insecurity, and to prove that they are worthy of respect, inclusion, and connection.
  3. Identify when their coping strategy is still used to cope with anxiety. Recognize if and how they still use that coping strategy as an adult. Most coping strategies used to ward off anxiety will diminish if the anxiety is faced head on rather than avoided with compulsions.
  4. Address underlying insecurity. Question their self-criticism and replace it with appreciation for their inherent individual strengths, rather than pathologizing or understanding them as reactive or defensive. Reframe their personality as potentially constructive. I’ve seen this perspective help many people as they participate in OCPD support groups.
  5. Help clients shift to a more “bottom-up” psychology. Nurture their capacity to identify emotions and learn from them rather than use compulsive behavior to avoid them. Help them to identify and live out the original sources of their compulsion, such as service, creation, and repair, actions that would give their lives more meaning. Help them to make choices based on how things feel rather than how they look.
  6. Identify what’s most important. Most compulsives have either lost track of what’s most important to them, or never knew. Projects and righteousness that they imagine will impress others fill the vacuum. Instead, once they can feel what they were naturally compelled to do, they can use their determination to fulfill it in a more satisfying way.
  7. Identify personality parts. Compulsives try to live in a way that is entirely based on direction from the superego, and they attempt to exclude other aspects of their personality. I have found it very helpful to have them to label the dominant voices in their head (Perfectionist, Problem Solver, Slavedriver), and to identify other personality parts that have been silenced or who operate in a stealth way. Depending on what the client is most comfortable with, we can use terms from Transactional Analysis (Parent, Adult, Child), Internal Family Systems (Exiles, Managers, Firefighters), or a Jungian/archetypal perspective (Judge, Persona, Orphan).
  8. Use the body, the present moment, and the therapeutic relationship. Compulsives rarely experience the present and usually drive their bodies as vehicles rather than nurture them. Bringing their attention to their moment-to-moment experience and using their experience of you as their therapist can help. For instance, bring their attention to tension in their body and, if possible, connect that with any feelings that they have about you. For instance, do they feel a need to comply with you, or any resentment about complying with you?

The Case of Bart

Background

A man in his early forties, whom I will call Bart, came to see me when his wife said she could no longer tolerate his worrying and unhappiness. To his own surprise, he found himself tearing up as he described his life to me. He didn’t do that kind of thing. Ever.

Bart was handsome, fit and bright. Yet he was very self-deprecating.

He told me that he worked in finance and had done well enough to provide comfortably for his family. But his success didn’t register with him at all. He worried about what others thought of him. He feared that people would discover that he was a hoax at his job; he believed his success was accidental and that he could lose it all at any time. At this point in his career, he was just coasting and didn’t find any meaning or challenge in it.

Bart imagined that his family tolerated him only because he provided for them. During our initial consultation, he said he wasn’t feeling bad. But it was clear that he had experienced serious depression in the past, and I suspected that he was still depressed but couldn’t acknowledge it.

His wife was lively, talkative, and highly social, but their relationship was flat at best. He made it a point to say that he did not want to blame her for any of his problems or theirs as a couple. Nor did he want to assign any blame to his parents. Any problems he had were of his own making.

He admitted that he found it difficult to engage feelings. He avoided reflection, journaling, and talking. Like most compulsives, he controlled not just the outer world, but also his inner world. It was hard for him to tolerate uncertainty.

He played organized sports about four days a week, and he had great difficulty tolerating any mistakes on the field or court. He constantly monitored success and failure with a scoreboard in his head. He had quit playing golf because he got too upset when he didn’t play well.

At the end of our initial consultation, I told him that it seemed to me that while he had adapted very well to the external world, he had not adapted well to his inner world. Achieving that would be one of the goals of our work together. I was confident that if he could put the same energy and attention that he had put into career success into his psychological well being, he would see change.

He told me that his impressions of therapy were based on media examples and that he didn’t have any idea how this worked. I told him that I was glad he was asking because we as therapists don’t always do a good job of explaining how the therapeutic process works. I agreed to be transparent about the course of our work, to share how I believed we needed to proceed, and to explain the rationale behind my suggestions. In particular, I would try to be clear about his role in the work.

Narrative

His mother was depressed and a classic martyr. Masochistic, even. She seemed to enjoy her suffering. His father worked as a salesman and was willful, driven, and judgmental. He insisted on success: winning was his religion. For Bart this meant that if his behavior didn’t lead to points on the scoreboard in terms of some productivity or success, it was meaningless. His father said, “it’s good to win.” Bart extended this to “it’s terrible to lose.”

Bart internalized the strategies of both parents, and it caused a terrible conflict: he had imperatives both to lose and suffer (his mother’s masochism), and to win and achieve (his father’s need to triumph). He chose to be more like his father from his teens until he was 25; then he switched and became more like his mother. But he couldn’t let go of the feeling that he should still be winning all the time, in addition to learning, producing, and working all the time. He had lots of “shoulds.”

He had concluded that people want compliance rather than authenticity. He was raised Roman Catholic, and he’d make up things he had done wrong to have something to admit when he went to confession. He told me that he no longer believed in God, so he had to punish himself now. He felt guilty about any sort of self-assertion. He loved post-apocalyptic films because “in that setting, you don’t have to worry about being good anymore.”

Yet Bart didn’t feel that his parents or his environment had any bearing on his current struggles. So I said that the most important thing for us now was to understand how he had adapted to the situation he was raised in.

Coping Strategy

One aspect of Bart’s strategy was trying to control people by giving them what they wanted. Meeting his father’s expectations was only the beginning. Among the four types of compulsives, he was clearly a follower/people-pleaser. He tried to achieve self-acceptance through others’ opinions of him, but it didn’t work, even when he did get accolades.

Another aspect of his strategy was to not depend on others. To do so would rob him of control. It would take time for him to realize that he actually did have social needs, but that, so far, those needs had only gone into impressing others, rather than relating to them. As with many compulsives, Bart felt it was safer to seek respect than to want love.

In his martyr mindset, being a victim implied that he was good. So he often became very negative about his life to prove to himself that he was a victim. He wouldn’t complain verbally to others, but he did need to show himself, at least, how bad his life was. Later he came to realize that his depressed moods were also unconscious attempts to communicate the misery that he could not reveal directly.

He was aware that he had adopted a strategy of planning and perfecting to try to pre-empt the utter self-contempt he unleashed on himself when things didn’t go well. “But why the self-contempt?” I asked. “If I’m self-critical, it will show other people that I won’t tolerate mistakes. But it’s become habitual. I do it even when other people aren’t looking.”

Engaging Feelings

Much of our work involved learning to identify feelings and excavating different levels of feeling so that he could operate from a more “bottom-up” approach. We spoke of therapy as a gymnasium for exercising his capacity to tune into feelings. As with many compulsives, framing our work in terms of a project was helpful in engaging him. I tried to bring attention to what he was feeling in his body and to the present moment.

Most of his feelings were about “shoulds.” Desires were few and far between. Tuning in to desires was a heavy lift for him, but with time he began to be more aware of the difference between acting on fears versus acting on desires.

At times Bart felt like giving up, whatever that might mean. I recommended that he take that seriously but not literally: What is it that you really need to give up? What is the control that you would be happier without?

As he let go of self-control, anger began to surface and eclipsed his sadness and anxiety. Part of him believed that he always did the right thing, and he got angry at those who didn’t. While he was typically self-effacing, it was new for him to acknowledge that in some ways he felt superior.

But we also needed to continue to excavate even more deeply beneath his anger and judgement to see if there were yet other levels of fear or sadness. While it was scary and sad to acknowledge how much was out of his control, it was a relief not to be avoiding it.

When he first came into treatment he had imagined that therapy would remove all his uncomfortable feelings. But with time he came to realize that it was okay to have feelings—sad, anxious or angry—and that he could learn not to amplify those feelings or carry them needlessly. With time, he didn’t need to avoid them so thoroughly.

Identifying What’s Important

Even as he learned to turn his focus inward, he found it hard to articulate his goals in life, career, and therapy. He had lost track of himself and what he really wanted long ago.

Because he had little access to feeling, he was unable to find direction. He obsessed about his job and whether to change companies or even careers. He liked the idea of a new career, especially one with a new identity, but he couldn’t follow through on that. He feared losing the fantasy of what it would be like if he did change.

As he navigated his professional and personal world, I often had to ask him what was most important to him. At first this was distressing, since he had no idea who he was or what he wanted. He was always climbing mountains, but he wasn’t sure whether taking on challenges was something he felt he was supposed to do or something he wanted to do. This skill of distinguishing how something looks from how it feels has been essential to the improvement of most of the people I work with. He couldn’t tell the difference, and we kept revisiting the distinction.

In his efforts to succeed, he’d lost track of why he wanted to succeed. Any sense of fulfillment in accomplishments was replaced by the need to achieve to prove to others and himself that he wasn’t a fraud. Over time he came to recognize that taking on challenges was fulfilling, that he genuinely enjoyed it, and that it was vital to his feeling better. But to enjoy it, he had to let go of using the challenges to prove his worth.

He had similar realizations when telling me about learning: this wasn’t just something he should do to silence his father’s demanding voice, it was something that was very satisfying. He didn’t have to do it, he wanted to do it. And that made it more pleasurable.

We explored his feelings about his marriage. He did value his marriage but was reluctant to depend on his wife: “I’d like to think that I don’t need my wife, but I do. And because I don’t want her to be too important, I don’t take in her support.” This would have made him too vulnerable and would have gone against the masochism he adopted from his mother.

It was a small revelation to him when he was recounting his weekend and noticed that spending time with his son had actually been pleasurable. It wasn’t just a “should.” Noticing this feeling of pleasure was a small window into what was most important for him. “I’ve been putting points in the wrong basket all along, thinking that making money was most important…I have to challenge the idea that piling one more dollar on the stack will make me feel better.”

He came to value more peaceful emotional states—being more present and accepting, and less regretful and judgmental.

Transference & Countertransference

Coming to therapy was not comfortable for Bart, partially because he felt he wasn’t “good” at it. “I remembered that he had quit playing golf because he wasn’t good at it and wondered to myself if the same could happen with therapy”. Still, his ability to speak to me directly about his discomfort was a success. Doing so served as a sort of psychoanalytic exposure therapy, staring down his deep fear of being real and of being known, with the added advantages of eventually understanding the causes and functions of those fears.

He once asked whether therapy was like confession. I explored what it was like in that regard for him and reminded him that when he was young he would make up sins to take to confession. Would he need to do that here? He didn’t think so.

He admitted that he wanted to learn the language of psychotherapy to please me. “Sometimes I tell you what I think you want to hear. I never lie to you, but I do try to figure out what you want.” He felt pressure in the silence to figure out what he was supposed to say. We explored this as a good example of his strategy.

“I’m afraid you think I’m a dick,” he said. “I’ve got so much, what’s my problem? Why am I complaining? You must think I’m just indulging here.” Was this feeling unique to our situation, or was this actually typical of how he felt with most people? He acknowledged that he never felt that it was okay to feel even tolerably accepting of himself, much less feel really good. That would be indulgent and arrogant. And it would invite humiliation.

He had imagined that I would give him a thumbs up at some point, certify him as mentally healthy, and send him on his way. We used this as an opportunity to distinguish what was more important: what I thought about him or how he felt about himself.

Allowing me to know him, and questioning how he imagined I saw him, was a step in the direction of being more open with people in general. Looking for parallels with what he imagined I thought of him, we explored the difference between what he imagined his wife thought of him, and what she really thought of him. As he felt less criticized, anxious, and depressed, she scrutinized him less, and he began to feel more comfortable with her.

“I also experienced my own discomfort with him”. I feared that he would run out of things to say and that I would be exposed as not having anything to offer him. I was not able to work this through completely, but in retrospect I suspect that my fears of being found inadequate were both induced and my own.

He missed a fair number of sessions. Even accounting for the fact that business meetings came up last minute, it still seemed that he avoided his issues at times by not coming. I thought it might be fitting for this to be an imperfect therapeutic process, and that my accepting that was going to be instrumental in his progress.

Despite how imperfect it was, he did make progress. Candor, which had been ego dystonic, was becoming ego syntonic. His coping strategy was changing, and we both came to enjoy his increasing freedom to be himself in the sessions.

Treatment Process: The Agents of Change

My goal in treatment with most compulsives is to enlist their natural impulse to become a “better” person and put it in service of their psychological growth. With Bart I never used the word compulsive, much less mention the diagnosis “OCPD.” But I did note his strong, natural drive to succeed and to be a good person.

Bart did seem to get this eventually: “It's kind of like I'm waking up and realizing that the game I was playing, putting points on the scoreboard, was meaningless, but this process of understanding myself and feeling better is more important. It feels good when I get it, when I master it.”

These realizations included questioning the narrative that he had to be like either of his parents. Near the end of his treatment he told me, “I want to take the best of my mother and father, and not be so black-and-white about it.”

Another aspect of his narrative that we needed to question was whether his family needed him only for money. Maybe they wanted him to be happy as well. Accepting this as a possibility required some vulnerability on his part. He couldn’t remain aloof if they actually cared about him. I believe that his work on opening to feelings in our sessions was instrumental in allowing him to feel closer to his family.

On occasion he wanted assignments for the week. I chose exercises to help him become more aware, in the moment, of how his old coping strategy affected him. For instance: “Try to notice when you stop yourself from feeling good. Count the times you do it. Just noticing it is great.” And, “Notice how many times perfectionism leads you to attack yourself.” Compulsives love to count. What he counted was changing.

We explored different parts of his personality. “What if I’m an asshole that just likes money? What if I just like being seen as generous but I’m really not?”

“Yes, part of you likes money, and part of you likes being seen as generous. Those are both okay. And there is more to you. There is also a part that genuinely likes to be generous whether anyone sees it or not.”

He wondered if it was okay to be ambitious. Somehow it didn’t feel right. The more we processed this, the clearer it became that it wasn’t so much money that was important to him, but achievement and mastery. There was a part of him that loved challenges. To say what he loved was a new expression and marked acceptance of a part of him that he had only vaguely recognized before.

Accepting his introversion was another challenge. He definitely liked his time alone but felt guilty about it, which of course meant that spending time with his wife and others felt like it was in the “should do” column, not the desire column. In the long run, he came to appreciate both being alone (without guilt) and spending time with his family, because it was no longer a “should.” As different parts of him came out of hiding, it became clearer what was important to him.

All these elements served to reduce the insecurity he felt, so that he didn’t need to prove himself…as much.

Termination

After 19 months Bart felt well enough to end treatment. We spent a few weeks processing the termination, especially what it was like for him to end it rather than me. I would have liked to see him longer, but that may have come out of my own perfectionist ideas about how long treatment should go on and what it should accomplish.

I would like to have seen him develop more comfort with the therapeutic process itself, but that too comes from someone whose intense interest in psychology developed when he was a teenager. Maybe not everyone needs to be comfortable with therapy, much less actually enjoy it. It was a very good sign that he decided to end treatment rather than feel he needed to stay to please me. I hope my acceptance was healing.

“I will never know how much, if any, of his progress was a well-performed recovery”. But I suspect that even if his first efforts to be authentic were to please me, they eventually became truly authentic. I suspect that he had experiences and insights that will help him change and be more fulfilled, even well after our work is finished.

Working with compulsives has forced me to examine my own biases, my own need to control, and my own rigidity. If nothing else, I learned that I can’t expect my patients to become any more flexible than I am myself. This includes challenging my own fixed ideas of how treatment should go with each new client.

Conclusion: Poison as Medicine

Jung said that individuation is a compulsive process, that we are compelled to become our true, authentic selves. When that process is blocked, neurotic compulsion ensues.

When we recognize the constructive potential of the obsessive-compulsive personality, we can help make it less “disordered.” When we recognize the energy that’s gotten off track, we can help direct that energy back toward its original, healthier path. The adamancy about doing the “right thing” that turned against the client and the people around them can be enlisted to help them find their way to a more satisfying way of living.

The alchemists were known for trying to transform lead into gold, which was really only a metaphor for transforming the poisonous, dark struggles of our lives into the incorruptible gold of character. But I think that this metaphor works best when we understand that the gold was there all along, obscured and waiting to be released.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Diedrich, A., & Voderholzer, U. (2015). Obsessive-compulsive personality disorder: a current review. Current Psychiatry Reports, 17(2), 2.

Haslam, N. (2003). The dimensional view of personality disorders: a review of the taxometric
evidence. Clin Psychol Rev, 23(1), 75-93.

Hertler, S. C. (2015). The evolutionary logic of the obsessive trait complex: Obsessive
compulsive personality disorder as a complementary behavioral syndrome. Psychological
Thought, 8(1), 17-34.

Koutoufa, I., & Furnham, A. (2014). Mental health literacy and obsessive–compulsive personality disorder. Psychiatry Research, 215(1), 223-228.

McIntosh, P., Paulsen, L. Mental health literacy of OCD and OCPD in a rural area. The Journal of Counseling Research and Practice, 4(1), 52-67. Available at https://egrove.olemiss.edu/jcrp/vol4/iss1/4.

McWilliams, N. (2014). Psychoanalytic Diagnosis. The Guildford Press.
Pinto, A. (2016). Treatment of obsessive-compulsive personality disorder. In E. A. Storch & A. B. Lewn (Eds.), Clinical handbook of obsessive-compulsive and related disorders (pp. 415-429). Springer International Publishing AG. 

Allen Frances on the DSM-5, Mental Illness and Humane Treatment

Posted on by rezendevknowfully.com

Where DSM-5 Went Wrong

Lawrence Rubin: I first became familiar with your work around five years ago when I was teaching abnormal psychology. So, I’ll start off by saying that you’ve had a very interesting professional evolution. You were involved in the preparation of the DSM-III series, chaired the DSM-IV task force, but then became a strident critic of its successor, the DSM-5. Were you as critical of the DSM-III and IV, as you were of 5?
Allen Frances, MD: Well, I worked on the DSM-III, and I was one of the conservative voices trying to restrict the enthusiasm for expanding diagnoses beyond what I thought would be reasonable. I did my best, mostly unsuccessfully to provide the check on what seemed to me to be an ever-expanding diagnostic system. For DSM-IV, we established very high thresholds for making changes. And it turned out that we included only two diagnoses from the 94 that had been submitted to us as suggestions. We told the people working on DSM-IV that they would have to prove with very careful literature, if you used data reanalysis in the field trials, that any change would do more harm than good. And when you have high standards, very few new innovations get included.So, my concern about DSM-5 was that the experts doing it were given just the opposite instructions; to take the diagnostic system more as a blank slate and to be creative.

And if I’ve learned anything during these 40 years I’ve worked on DSM’s, it’s that if anything can be misused, it will be misused, especially if there’s a financial incentive.

And pharma, the big drug companies, have a tremendous financial incentive in making sure that every DSM decision is misused by expansion, so that people who are basically checked well are treated as if they’re sick. They become the best customers for pills. And drug companies have become experts in selling the ill to peddle the pill. So, I was very concerned the DSM-5 would have the negative effect of opening the floodgates even further to what seems to me to be fairly wild diagnosing, excessive use of medication, especially in kids, but also in adults and geriatric populations.

LR: So get as many new diagnoses out there as we can; make money, comport with the drug companies.
AF: I think that’s a misunderstanding. The people doing this were not doing this as an effort to curry favor among the drug companies, although many of them had some connection, a financial connection with pharma. I don’t think that that’s the motivation that lead to the DSM-5 expansions. I think intellectual conflicts of interest are much more important, and much more difficult to control than financial. And the experts in the field are always in the direction of expanding their pet diagnosis. They can always imagine a patient they’ve seen, who couldn’t fit into the existing criteria, and they worried very little about false positives.They were much more concerned about missing a patient, than mislabeling someone who shouldn’t be diagnosed. I think the people working on DSM-5 were honest. I don’t think that they had any inclination to help the drug companies, but their own experiences as experts in the field don’t generalize well to average practice.So, if you’re working as a research psychiatrist on a very exotic condition at a university clinic seeing highly selected patients, having lots of time with every patient, using careful diagnostic instruments, you get an idea about what might make sense. That’s completely inappropriate for primary care practice, where most of the diagnosis is done, and most of the medication is prescribed. I think experts were making decisions that might be reasonable in their own hands, but that would be absolutely dreadful once used widely in general practice.

LR: So, just a seeming disconnect between the researchers in these rarefied atmospheres and those frontline folks seeing people day to day!
AF: Exactly. And I think that this goes for all manifestations; what we see in psychiatry is not at all special to it. That every single branch of medicine has an inherent systematic bias towards overdiagnosis. Recently, the new guidelines on hypertension resulted in something like 40 million additional people being called hypertensive.Guidelines should not be left in the hands of professional associations. They should be done by people who are neutral. And use experts, but don’t allow them to call the final shots

A Diagnosis Should be Written in Pencil

LR: Have you seen any discernible impact of your anti DSM-5 sentiments in the last five years since its publication? Has the field shifted back to listening to some of the concerns that you and others have had in terms of overdiagnosis and lowering thresholds?
AF: Yeah. And again, it’s not just psychiatry. This has been a problem in every single medical and surgical specialty. And there is an increasing chorus of Davids fighting the huge Goliaths. The huge Goliaths in this case are the drug companies and the professional specialty organizations who have vested interest. The medical industrial complex is now a $3 trillion-dollar industry. And it is most profitable when people who are basically well, feel sick, and get treatments they don’t need. And so, its tremendous budgets are expanded by the demand of all medicine in the direction of increasing patienthood and recommending ever more expensive treatments.The Davids fighting this are just a small group of people with very limited budgets, but sometimes right does make for might. And the medical journals in general have become much more aware of overdiagnosis. I’ll be at two meetings this summer, one in Helsinki, and one in Copenhagen, both focused not just on psychiatry, but across medicine and surgery on the topic of overdiagnosis. There’s an institute called the Lown Institute that’s working very hard to promote right care rather than excessive care. And there’s a wonderful initiative called Choosing Wisely, in which the various medical specialties are identifying those areas, where there’s excessive diagnoses and treatment.And I think in psychiatry and psychology, there’s been an increased realization that there are risks to diagnoses as well as benefits. And seeing any individual patient, it’s very important to adapt the general guidelines to that person’s specific situation, and to ensure that a diagnosis will be more helpful than harmful. It’s the easiest thing in the world to give a diagnosis. It only takes a few mindless minutes, and very often diagnoses are given precisely that way. Eighty percent of medication is dispensed in primary care practice, often after visits of less than ten minutes. A diagnosis once given, can have terrible consequences that haunt and last a lifetime.

And so, from my perspective, a diagnosis should be a very particular moment in a patient’s life. It should be, when done well, a very important positive moment.

A good diagnosis leads to feeling understood, to no longer having a sense of confusion and uncertainty about the future.  It helps the patient develop, with the doctor or the psychologist a treatment plan that may have a tremendous positive influence on their future. An inaccurate diagnosis carries unnecessary stigma and the likelihood of medication that will do more harm than good. And again, that haunting inability to ever get it erased. Because things evolve over time and people change from week to week, people usually come for help at their worst moment, and how they look at that moment may not be characteristic of their past or predictive of their future. I think it’s crucially important to take diagnosis seriously. A great way of putting this is a diagnosis should be written in pencil.

LR: I like that.
AF: Especially in kids.

On the Diagnosis of Children

LR: It seems that what you’re saying is that there’s this overt and covert attempt to enfeeble consumers. And you’ve written a lot online recently and seem really upset about what’s going on with children. Research seems to say that one in five are diagnosable, and one in 68 is on the autism spectrum. And you talked about stigma lasting a lifetime. Do you see that this is particularly the case when we hand out diagnoses to kids at very tender ages?
AF: First of all, never believe survey results that say one in X number of kids has the diagnosis. There’s an enormous systematic bias in all epidemiological studies. These are usually done by telephone, or by self-report, and they can never judge clinical significance. So, they’re only screeners that would at best provide an upper limit on the regular diagnosis, never a true rate but they’re not reported that way. And once it gets out, you know, it used to be that 1 in 2,000 or fewer kids had a diagnosis of autism. We changed that. One of the changes in DSM-IV was adding Asperger’s, which did dramatically increase the rate. But we expected the rate to increase by three times, not to go from 1 in 2,000 to 1 in 50, which has happened over the period of these last 20 years.And I think that some of that is identification of people who previously didn’t get the diagnosis and needed it, but a lot of it has to do with wild generalist diagnoses, and survey methods that are very misleading. I think that kids are very changeable, from week to week, and month to month. There are changes in development that are responsive to family stress and school stress, peer pressure. And what happens instead is we have wild overdiagnosis in attention deficit disorder and autism and this is done in a way that doesn’t respect the fact that these are young brains.We don’t know the impact of long term medication on the developing brain. It’s like a public health experiment that’s being done without informed consent. And all the indications for ADHD is that the beneficial results are short term. That academic performance over the long term is not positively impacted. That we should be a lot more cautious, both in diagnosis and in treatment, especially with young kids where diagnosis is so difficult, and where treatment may have negative as well as positive impacts. The most dramatic example of this is attention deficit disorder. There are five studies in different countries with millions of patients – not millions of patients, but millions of kids –and these have found that the best predictor of getting a diagnosis of ADHD and being treated for it with medication is whether you’re the youngest kid in the class. The youngest in the class is almost twice as likely to be diagnosed and treated than the oldest kid, which is clear cut proof positive, slam-bang evidence of overdiagnosis. Their immaturity is being turned into a disease, and kids are being treated with medication for basically just their immaturity. And the fact that the classrooms they’re in are too chaotic, and don’t have enough gym time, and don’t have enough individual attention.

LR: A woman wrote a chapter for one of my books, Mental Illness in Popular Media, on the use of adenoidectomies and tonsillectomies in the early part of the 20th century to deal with the seeming epidemic of kids who would today be diagnosed with ADHD. There seems to be this history of medicalization of childhood that you’re alluding to, and this perverse need we seem to have to enfeeble kids. And if anything, it seems that it will keep them more dependent, less productive, and less competent than ever before-an unintended side effect.
AF: I was one of the kids, who might have gotten the tonsillectomy.
LR: Me too.
AF: I remember that well. My father said “no, we’re not going to do that,” but the doctor recommended it, and all the kids on the block had gotten tonsillectomies. Medical diagnosis and treatment tends to run in fads. Over the course of history, there have been diagnoses and treatments that have sudden runs of popularity that now seem absurd. And some of our practices today will seem very troubling when looked at in the coming decades.
LR: Do you see Disruptive Mood Dysregulation Disorder (DMDD) as being part of this fad bandwagon? And even though it’s got this fancy name, it’s still considered child bipolar disorder, and that’s really damming.
AF: What happened here was really nuts. There had been suggestions by psychiatrists heavily funded by the drug industry to include the child version of bipolar disorder in DSM-IV. And we rejected those suggestions, fearing that it would lead to a tremendous overdiagnosis of bipolar disorder in kids. Despite our rejection, the diagnosis suddenly became popular, partly because the drug companies finance these guys to go around the country giving conferences and partly because child psychiatrists can sometimes be very gullible. And very young children, even infants were getting antipsychotics for a fake bipolar disorder diagnosed in the early years of life. The field of child psychiatry became concerned about this and wanted to correct it, but the fix in DSM-5 was exactly wrongheaded. What should have been done is a black box, a warning in DSM-5 about the overdiagnosis of childhood bipolar disorder. And the caution that the kids should be seen carefully and over long periods of time, and that they should meet criteria before a diagnosis of bipolar was made.
LR: A black box warning?
AF: There should have been a warning about the dangerous fad. Instead, they substituted a new diagnosis that essentially is childhood temper tantrums, hoping the kids who previously had been mislabeled bipolar would get this lesser diagnosis instead, lesser because it wouldn’t imply the need for mood disorder medications that would imply a lifelong course. But why substitute a new diagnosis for temper tantrums that can be so easily misused.The system tends to accrete, rather than to sunset diagnoses. It tends to always be adding new things, rather than warning about, or eliminating things that are already in the system that may be dangerous. So, parents have to be very well-informed about their kids.

LR: And they’re not.
AF: And the concern often is, if I don’t get my kid a diagnosis, say of ADHD and medication, he’ll be behind in school. I think parents have to have the opposite concern, as well that the medications are being given out way too loosely, and they need to protect their kids from medication that may not be needed.That said, I get more criticism, from people who feel I defend medication too much. I’m absolutely convinced that medication is useful, when given carefully to the few. That it becomes harmful only when it’s handed out carelessly to the many. And the people who go in either direction, either blindly supporting the use of medication, or blindly opposing it, I think of both as extremist, and they do harm to the real needs of the people. But there will be, and are, a large number of people who need medication and can’t get it, either because of inadequate resources or problems with financing treatment. And we have to worry about the people who are neglected very much. At the same time, we have to be mindful of the fact that we have the paradox of over-treating people, who are basically well, while we’re neglecting those who are really in need and desperately unable to get the treatment that would be helpful for them.
LR: You wrote a blog post titled, “Please empathize with me, doctor!” And from what you’re describing Allen, it seems that we are struggling with a societal empathy deficit disorder. There seems to be a preference for scientizing our relationship with kids and with our patients at the expense of understanding, at the expense of taking the requisite time. And at the really painful expense of not empathizing with these people, who are just going to be tossed into the system with labels and scripts. Empathy deficit disorder, maybe it will be in DSM-VI, or DSM-2.0.
AF: We could use it for our president.
LR: We’ll save that for later.
AF: Actually, the issue goes all the way back to Hippocrates, the father of medicine 2,500 years ago.

But First, Do No Harm

LR: Do no harm.
AF: Do no harm. He also said that it’s more important to know the patient who has the disease, than the disease the patient has. I don’t trust clinicians who only do DSM check lists. They don’t know the patient. I don’t trust clinicians who don’t know DSM and do free-floating evaluations that don’t take into account the ways that the individual may have a problem that’s been well described and has a set of guidelines that will be very helpful. I think that every clinical encounter needs to be a combination of close person-to-person collaboration, that the DSM guideline should never be applied blindly to each individual because they vary within themselves. It has to be customized for that particular person’s own situation. At the same time, not knowing the DSM diagnoses is likely to result in missing things that would be crucially important in treatment planning.
LR: False negatives.
AF: Good interviewers are people who are able to form great relationships with their patients, work collaboratively in understanding the diagnosis and planning a treatment and able to use the DSM without worshiping it.
LR: It seems that what’s needed, as you say is more time, a deeper understanding and a reluctance to jump into a diagnosis. This seems antithetical to the way that psychiatry and even psychology are practiced today. And clinicians are under more and more pressure to assign a rapid diagnosis and develop a treatment plan within the first session or two. What advice do you have for clinicians who are under this type of pressure, and may not have the luxury of flexibility and time that we know is necessary?
AF: Well, first-off, the system is crazy. Insurance companies do this because they think it will restrict costs, but it has the perverse effect of forcing people to make premature decisions that often will result in more costly treatment. Giving a person a medication is likely to create a commitment to see that patient over a long period of time. Diagnosis can increase the lifelong cost of taking care of that person. If the insurance companies gave more time for evaluation, many, many of the problems that get a diagnosis and long-term treatment would pretty much go away on their own with time and simple advice.The system is counterproductive; the more time we spend upfront with people in the evaluation process, before diagnosis and before treatment, the fewer diagnoses will be necessary, the less lifetime treatment will be needed. And it will actually be much more cost effective to give people time to get to know the situation at the beginning. I think for practitioners, it’s important always to underdiagnose. That it’s crucial to first of all rule out the possible role of medication and symptoms. You know, very often, hundreds and hundreds of times in my career, new symptoms have been due to medication.
LR: Iatrogenic?
AF: The average person over 60 to 65 is taking five, six, seven pills. Recent studies showed how many of them have depression and anxiety as side effects. And the older people particularly are less able to clear medications. So, you have a combination of a bunch of medications that can cause side effects, and a person not being able to clear those medications. And new symptoms are often treated with yet another medication, rather than realizing it’s a side effect. I think that it’s important to rule out medications. It’s important to rule out substances. It’s important to rule out medical problems. That has to be done during the first sessions. I think that’s crucial. But beyond that, I think it’s important not to jump to lifelong diagnoses based on very limited information. And to tend, at the beginning at least, to normalize, rather than to pathologize the situation.We see people on the worst days of their lives and tend to draw conclusions about them. And their futures are often inaccurate. They look very different days and weeks later.

Mind, Body or Both

LR: How can the average psychotherapist develop a healthier relationship with the biopsychosocial model? I know you said, you have to look for substance abuse. You have to look at the iatrogenic effects of medication. You have to look at the psychotropics that they’re on. So, how does the average psychotherapist, who is not particularly savvy when it comes to psychotropics, really have a full biopsychosocial understanding of these complex organisms that are people?
AF: I think one of the great losses over time has been the biopsychosocial model, particularly because of the mindless warring between people who have narrow views that are biological, or just psychological, or just social. I think that it’s impossible to understand the complexities of human nature and of how we function and dysfunction without taking into account the biological, the psychological, and the social, and sometimes there’s spiritual issues that people come with. And I think it’s just as important that psychiatrists be good psychotherapists and understand the way that social pressures result in symptoms. And it’s equally important that psychologists understand diagnosis and also the use of medication. Even if you’re not prescribing it, it’s very important to understand when to and when not to use medication. If for no other reason, to make sure the patient’s not getting too much medication, as well as knowing when to refer. I think every clinician needs to be complete. I don’t think that training in one discipline gives permission not to be aware of the tools that are available more widely across disciplines.
LR: Do you think there’s such a thing as a psychosocial reductionism? I know there’s biomedical reductionism. Do you see a danger at the other end of the extreme, of psychosocial reductionism?
AF: Oh, definitely. Psychosocial reductionism, yeah, it’s alive and well, particularly in Britain where there’s an ongoing back and forth. An active segment of British psychologists has taken a pretty radical view that psychosis is on a continuum with normal. That biological elements have been way over-emphasized in schizophrenia. And that most of the problems patients present have to do with childhood trauma. And again, every point of view has value, but no one point of view is necessary and sufficient.
LR: There are many truths. There’s just as much psychosocial reductionism as there is biological reductionism in many of these debates. You know, talking about biomedical and psychosocial reductionism, I remember when, around the time that DSM-5 came out, NIMH really took a stand and said, “Yeah, nice work boys and girls, but we’re going to pretty much move to the RDoC.” A lot of psychotherapists practicing day to day, who don’t work in academia, don’t read a lot of the scholarly journals, don’t have the bloodiest idea of what the Research Domain Criteria is. Do you see that system as useful or valid? Specifically, how useful do you see it in alleviating some of these ills of overdiagnosis and wrongheaded treatment?
AF: Well, the DSM had tremendous promise as a research tool, but it’s failed in that the complexities of brain functioning, of genetics, have been so enormous, the more we learn, the more we realize how little we understand.The brain is the most complicated thing in the known universe. It reveals it secrets very slowly.  And it turns out that there are hundreds of genes involved in schizophrenia and every other psychiatric disorder, not just a few. And all of the neuroscience research has been remarkably productive. One of the great intellectual adventures of our time is the research that’s been done on how the brain works; however it hasn’t helped a single patient!

I think we have to be aware of the fact that there are no low-hanging fruits. That we’re not going to have breakthroughs that will explain schizophrenia or bipolar disorder. That each of these conditions is probably hundreds of thousands of different conditions that share some clinical features, but probably have very different biological underpinnings. And we shouldn’t be so dazzled by the science that we lose track of taking care of real patients in the present. I think there’s so much promise, so many high promises in the future, and our NIMH budget is being spent almost exclusively on basic science research, almost not at all on clinical research, that we’re ignoring the needs of patient today.

To me, it’s a tragedy that we have 350,000 patients in prisons, and 250,000 homeless on the street that we’re taking minimal care of, we’re neglecting people desperately in need. And that most of the research has its head in the air trying to find out things that maybe are going to be helpful to a tiny percentage of patients in the future. Meanwhile, we know how to take care of people now, we’re just not doing it.

We’re not making the investment in community treatment, housing, recovery programs, that would be necessary to eliminate the shame on our country. Almost every other developed country takes much better care of their mentally ill than we do. The U.S. is the worst place in the country to be severely ill. And it’s not a matter of neuroscience or science in general, it’s just the common sense, practical taking care of people and treating them as citizens, not neglecting them. And what we do in this country is provide almost no funding for community treatment and support

LR: It goes back to this idea of empathy deficit disorder. You talk about science, I like the point you make about the RDoC. That it’s a magnificent academic tool, but maybe in the year 2635, we’ll find a gene for some component of bipolar disorder, but how many people are going to struggle and lose their lives before that?
AF: And I don’t think we will find the gene. I think what we’ll find, it’s like breast cancer, we’ll find that there are certain genes predisposed in a very small percentage of the people who have the disorder. And that’s the complexity. There’s a paper that came out that had 250 authors that found 105 genes for schizophrenia, each of them a tiny bit different than normal. And the permutations and combinations of those genes would be astronomical. What that says is that the complexity of these disorders is so great that there will be no simple answers. In the meantime, we shouldn’t be allowing people to not have treatment and not have housing and to wind up in jail. And the resources, the techniques, the ways of preventing this, of making our country less of a shameful outlier in how we treat the mentally ill are perfectly obvious, it’s just a matter of funding and political will. And the severely mentally ill are the most disadvantaged, the most vulnerable population in our country.

It is the Relationship That Heals

LR: I find a bizarre paradox in all this. When I think of psychosocial treatment, I think of the amount of money, time, resources, the human capital, that’s being spent to develop these empirically supported treatments, and ultimately you end up with cognitive behavior therapy at the top of the heap. There seems to be this manic pull in psychology and psychotherapy to develop empirically supported treatments, which many argue take the heart and soul out of the human connection, out of psychotherapy. Do you have any thoughts about this scientific perversion and how it’s affected the field of, and the practice of psychotherapy?
AF: I don’t think it’s so much scientific perversion. I think it’s economic pressures; that every therapy wants to gain a list of insurance companies who will pay for it. And this leads to a kind of competition to prove that your work is validated. I’ve been following this field now for 40 years. I was on the NIMH committee that used to fund psychotherapy projects that no longer exist, of course, because of NIMH’s current focus on the brain. But the overwhelming finding in the literature is that all of – this is a paper that was published 40 years ago by Lester Luborsky – all have run, all have won, and all deserve prizes. That all psychotherapies can be helpful. More of the outcome, of the variance in outcomes is returned by the therapist through a client relationship, than it is by specific techniques. That it’s kind of silly to have a competition amongst therapy techniques because all are necessary.I think to be a therapist, you should be well-versed in every single type of therapy, because patients vary between, and also even within themselves and what they need in a given moment. And it’s not as if one, as if cognitive techniques are inherently better than techniques that focus on psychology or the social situation. Different techniques are going to be different at different moments. And the technique in general is useful only in the context of a relationship that’s nurturing and healing. And the most important thing in the healing of psychotherapy is probably the nature of the relationship, and the need for a personal match between the two people. I think that it’s been an unfortunate – there’s been an unfortunate tendency to develop competitions. Competitions between medications versus psychosocial approaches. Competitions among the various psychotherapy techniques.A really well-rounded clinician has to be good at everything, and especially has to be good at relating to the people that they’re trying to treat.

LR: I have to tell you Allen, it’s refreshing to hear a medical man, a psychiatrist in particular, especially one who is that connected to the history of the DSM know about the Dodo effect, and to really appreciate that. So, you have the average therapist working in the average practice in a community mental health center, maybe even in a homeless shelter, recognizing that the technique is not nearly as important as the relationship. And then they come across a client, who seems psychotic in the moment, or seems to have a history from limited information of bipolar disorder or schizophrenia, and their knee-jerk reaction may be “I have to get this person to a psychiatrist. I have to find out what’s medically wrong with them.” What does that average line worker do, knowing in their heart that their relationship is critical, but that they have this biomedical pressure to refer to a psychiatrist, or even a primary care physician?
AF: Well, I think everything is important. You mentioned primary care physicians. People with schizophrenia die 20 years earlier than the rest of the population. And that gulf has increased in recent years and is much higher in the U.S. than it is in other country, because we neglect the people so much. There isn’t one answer.

Taking it to the Streets

There’s not one size fits all. And there isn’t one answer to people who have tremendous problems at every level. I mean, the first thing with a homeless person might be sharing some orange juice. It’s forming a relationship. It’s finding out a way where they can have housing. It’s not as if the answer to our blanket neglect is going to be getting an appointment once a month with the psychiatrist and getting a pill. That may be a necessary part of the plan, but certainly won’t be sufficient.

Los Angeles is now embarking on what may be the most encouraging experiment in taking care of the severely mentally ill that I’ve seen in this country in the least 40 years. It will be an approach that will be actually a combination of getting out to where the people are who need help, figuring out what they want, and helping them get it. You know, maybe the first step is providing showers, and a welcoming environment, and a place to have lunch. And the housing is going to be probably more important than treatment.

If you can’t get someone a decent place to live, the rest of the treatment is going to be very hard to carry out.

We have to figure out a way of getting the patients out of prisons and getting the people on the street into decent places to live. We had all of this until the Reagan Administration in 1980. The community mental health centers and housing were an increasing and exciting part of the care. We led the world in the ‘60s and ‘70s, in trying to devise community treatments. And now we are at the very bottom of the pack, one of the most heartless places in the world. One of the worst places in the world if you’re mentally ill. It’s not going to be a solution that takes into account just one need. It’s going to have to be a kind of total approach that includes the police, the sheriffs, the prisons, the district attorneys, the judges and the politicians. And that’s exactly what’s happening now in Los Angeles, and that may serve hopefully as a model for the rest of the country.

LR: As a psychotherapist, I listen to the inflections and the changing tone in your voice. And there’s such enthusiasm and energy when you talk about all that can be. And there’s a discernible lilt in your voice, almost a down-turning in your overall demeanor when you talk about the way things are.
AF: I think one of the things that’s crucially important to understand is that the symptoms we see in the very ill aren’t necessarily inherent to their condition, but rather maybe a reaction to the social context in which they’re living. The example 60 years ago was we kept people warehoused in terrible snake pit state hospitals. And the observation was that the hospitals were making them sicker, because of the social neglect within in. What’s happening now in the United States is that by neglecting people and leaving them without treatment and without housing on the street, we see much sicker patients here than in other countries that provide better care.So, the paradigm of good care here is Trieste. And I’ve heard over many years, how wonderful the Trieste system was in treating the severely ill, without hospitals, without restraint, and with minimal medication, but not the high doses and multiple medicines that are given in the United States. And I never believed it until I visited. And now I’ve been there three times over the last five years, and it’s an absolute miracle. Trieste takes good care of the people with severe mental illness and treats them like citizens. It has social clubs for them and a career path. The Trieste Mental Health System runs two hotels, five cafes, a car service, and a landscaping business, so that people who start out as patients, wind up working in the system. They have housing. They take good care, and they treat people with respect. And their patients are a lot less sick than ours.They just don’t get to the levels of psychopathology that we see in this country because there’s such neglect along the way. And the message in this is, treating the casualties, the train wrecks, is a lot more expensive and heart breaking than doing the right thing at the right time, earlier in the course before the illness progresses. I think there is a tremendous shame as a civilization that what we’ve done is fail to provide.

Ever since the Reagan Administration, we’ve failed to provide community housing and community treatment, rehab, and recovery. And instead we hospitalize hundreds of thousands of individuals in prison.  We’ve imprisoned hundreds of thousands of individuals, who should be in community programs, and maybe very occasional inpatient stays. We see them on the street every day and I just pass them by. My hope is that Los Angeles will be a beacon that things can be different.

LR: Is the Trieste system similar to L’Arche?
AF: It actually started in the ‘60s, with the closing of the large mental hospitals in Italy. And the system is based on the idea that everyone can be helped, everyone’s a citizen, everyone deserves respect, and that the community funds adequate social programs and treatment programs, and housing programs, and job programs. And they make the assumption that each person can be a useful citizen in the community. And when people get sick, instead of throwing them in a hospital and keeping them there for a long time or throwing them into prison which is what we do, or instead of keeping them on the street, there is tremendous concern for them and individual attention for them in figuring out a way back to health. And it just works. It’s miraculous. And people don’t ever get as sick as the people we see on the streets and in our prisons and our emergency rooms, because they’re treated with respect and care.

Reaganomics and Mental Health Care

LR: What do you think happened back in the Reagan era that directed us away from compassion, and away from potential? What happened?
AF: I mean, it’s very clear, this history couldn’t be more explicit and disheartening. The Kennedy Family, because they had mistreated one of their family members, had a huge personal interest in this themselves. In the ‘60s, there was the first use of medications to help people who were previously hospitalized to live in the community. And there was a bill, the Community Mental Health Center Bill that established all across America, the notion that we could help the individuals better in the community than by warehousing them in state hospitals. The money was meant to come from the state hospitals, so it seemed like and was a tremendously cost-effective transformation that we would close the state hospitals, and instead spend the money on community services and housing. And with the provision the medication people could be managed, creating for them to live much better lives outside of hospitals than within, and it would be cheaper.All of this was working. I worked in places in the ‘60s and early ‘70s that were quite remarkable in helping people find new lives outside the hospital. What Reagan did in the ‘80s was to send block grants, and this should sound familiar because it’s exactly what Trump wants to be doing now. Instead of providing federal support for these programs, Reagan said we’ll take this money and send it back to the states and them let them spend it the way they want to spend it. And what the states did almost uniformly was either use the money to reduce taxes, or use the money for other priorities or general funds. And the community mental health centers were gradually defunded and privatized. And private systems will never take care of the severely ill, because they’re expensive to take care of. So, the community mental health centers that survived, did so by restricting themselves to healthier patients, who had more money and fewer needs.And some went out of business altogether, some switched into behavioral health centers, treating people who were much healthier and neglecting those who were really ill. So, what we did in the ‘80s was destroy what in the ‘60s and ‘70s was the most innovative and one of the most effective [community mental health] systems in the world. The rest of the world continued to care for the mentally ill in a much more humane way, and it gets much, much better results. And the paradox in the states was that with the closing of the community mental health centers, many of the individuals untreated on the street committed petty crimes and sometimes not so petty crimes that resulted in their being in prison. And we’ve had this tremendous increase in the number of prison beds so that the LA County Jail is the biggest psychiatric facility in America. And in many states, the biggest psychiatric facility is now a prison. That the money that should have been spent on community treatment that had been spent on snake pit hospitals is now spent on prisons, and there’s kind of prison industrial complex that keeps that going.

LR: So, it’s a reactionary swing back to the early part of the 20th Century, when criminals and the mentally ill were merged. And a misappropriation of funds.The Republican agenda to decentralize the federal government, combined with various historical, sociological and financial factors, and these poor people were and are just caught in the crosshairs.
AF: Yeah, until the early 1800s, psychiatric patients were criminalized, along with prisoners and the poor in horrible facilities. The father of psychiatry is Pinel. And in the early 1800s, he freed the patients from the chains, treated them like decent human beings and citizens, and got remarkable results. And that led to the state hospital movement which was originally a positive movement…
LR: A community.
AF: Yeah, gave people a place to live and work. And they usually had farms, they had workshops. And it was only if these became overcrowded in the early parts of the 20th Century, that they turned into snake pits and asylums. That led to the deinstitutionalization movement that began in the late ‘50s and early ‘60s. And it led to a community mental health center movement that was really quite encouraging and effective in the ‘60s, ‘70s, and early ‘80s. And that was pretty much destroyed from the mid ‘80s on. And at this point, we have very few effective community mental health center initiatives in our country, and we have lots of prisons treating the mentally ill, and the mentally ill on street corners in all the major cities.
LR: A reactionary swing back to the past.
AF: Privatization doesn’t work. I mean, if we’ve learned anything about healthcare, mental healthcare, and healthcare in general, it is that a for-profit system will result in way too much treatment for people who don’t need it, and way too little treatment for the people who do.
LR: So, we need psychotherapists out there as social workers more or less. Maybe more training at the graduate level, at least in psychology and counseling in the direction of community mental health and social advocacy.
AF: In all of the mental health fields, there’s been way too much attention to treating the easy patient and the well-paying patient, and way too little of taking care of the people, who really need our help. And I think that the most wonderful experiences of my life have been the saves of people who seem to be beyond saving. And anyone can treat someone who doesn’t really need treatment.
LR: Right.
AF: We should be trying to focus our attention on those who really need us.

The Twilight of American Sanity

LR: We’re sort of winding down and I wanted to ask about this irrepressible current in you…about the impetus for writing Twilight of American Sanity: A Psychiatrist Analyzes the Age of Trump, and what you think is going on in government and in our society? I see Trump as a symptom rather than the disease, but would you mind talking about what you think is going on, from a psychiatric, psychological point of view?
AF: I started writing the book well before Trump began running for office. I’m concerned for my children and grandchildren, and the future generations more generally, about the fact that our society was delusional in ignoring global warming, overpopulation and resource depletion. And a bunch of other problems that are so obvious and common sense just sliding right by, as if we can hand on to the next generation a world that’s degraded and dangerous. And so that was before Trump. Trump is a mirror to our soul and the reflection ain’t pretty.And he is a symptom, not the cause, but he’s certainly making the disease much worse. I think there has never been a threat to American democracy like this one since 1860. And this election, this midterm election is to me the third most consequential election in the history of our country, the other two being 1860 with Lincoln’s election, and 1932 with Roosevelt. I think that Trump is a direct danger to our democracy. His attack on the free press, on the court systems, on the institutional checks and balances is not a joke. And that at this point, the sides are fixed. I don’t think either side is going to give into the others. And I think the crucial thing will be the vote, getting out the vote. And anyone who cares about this country, and cares about – I think that Trump could be responsible for more deaths in the next century than Hitler or Stalin and Mao combined. I think global warming is an existential threat to our species. And that we don’t know where the tipping point is, but we’re likely approaching it without taking out an insurance policy.People in their individual lives have insurance policies even though they don’t expect to die tomorrow, or have a fire, or an accident, you just protect the future. And we’re tripping over the cliff of global warming without taking an insurance policy for our kids and grandkids, that the world will be livable for them. I feel a sense of despair if our country is not able to right itself. And it was a wonderful thing that we were able to elect a black president ten years ago. It will be a much worse horrible terrifying future if at this point we re-elect the people who have been willing to give Trump such a wide leeway in destroying our country and our world.

LR: Well said. I think that we have a responsibility as therapists, as mental health clinicians to be aware of what’s going on because many of our clients are the day-to-day recipients of some of the changes in policy that are being created. I think psychologist, psychotherapists, psychiatrists, need to be politically aware without becoming politically depressed.
AF: I think it’s important not to be psychologically name-calling Trump. Thinking of Trump as crazy, tremendously underestimates his evil and cunning. We have to fight Trump with political tools, not with psychological tools. I think as therapists, we need to help most of our patients – I think you can’t politicize treatment.And so, a good therapist should be able to treat someone who is a Trumpists and should not try to get into political discussions with their clients and patients. I think as citizens, it’s an important thing for every therapist who cares about the social safety net of our country. The biggest factors with mental illness don’t come from within psychology and psychiatry. The biggest factors of mental illness come from social forces.Inequality or poverty are tremendous drivers of mental illness. I think it’s a responsibility for therapists to be political, not in calling Trump names but rather in getting out the vote. There’s the Kansas thing and getting their friends to register, getting their family members to register. Because I think everything has to do at this point with the numbers of people who show up in November. And I think there may be some therapists who support Trump, it’s hard to imagine, but by and large, most therapists and most people they know will be on the side of trying to protect democracy and protect our environment. And so, I think the most important thing a therapist can do at this point is to help get out the vote.

LR: Do you think mental health treatment and funding for mental health at the community level is in danger, with this and similar administrations?
AF: Oh, yeah, Trump recently, yesterday, there was a news report that what the Republicans are going to try to do to cut Obamacare is to cut out the [mental health] parity elements in plans.
LR: All that work! All that work!
AF: And the Medicaid funding of the original Trumpcare bills was to do block grants, rather than to be supporting mental health, which is exactly what Reagan did.Our patients are being targeted by the irresponsible GOP Congress and by Trump.

LR: We don’t want to end this conversation on a depressing note.
AF: Well, the good news is that things are flexible, and that ten years ago we elected a black president, two years ago we elected a black-hearted president. And the country is fickle, and things are very much in the balance. And it is conceivable to me that we’re heading down the drain to a fascist autocracy. And billions of people dying in global warming in the next century. It’s also conceivable to me that there are fixers, and that this is a temporary worst moment and things have to look better. And really, I think it’s in the hands of who votes in November.

The Relationship is All

LR: I guess this is sort of a summary question – if you were to look back and advise a younger Allen Frances, what advice would you have given him early on his career that might have changed his direction, or are you pretty content the way it’s played out?
AF: It played out mostly by accident, and then it’s just doing your job. I don’t think that there’s – I think, there’s actually one advice to people; it’s listening to the clients/patients you’re working with and learn from them.
LR: They’re our best teachers if we let them.
AF: And be yourself. You can learn everything, but also be yourself.
LR: It’s refreshing, again coming from a psychiatrist, just on a personal note, my brother is a psychiatrist, retiring at the end of this month after 40 years. He’s cleaning up his slate of 350 patients. And I wonder what it will be like for him as he looks back on his career. How many did he help, and which ones stand out. Do you have any one particular client story that inspires you?
AF: I think this is the most telling thing, and this might be helpful to people. That I’ve treated people for 14 years and had no impact on their lives. I’ve worked in emergency rooms my whole career. And I’ve seen people for five minutes and they’d come back years later and said, you said that and it changed my life. You never know when what you say may have a tremendous impact on someone. And so, every contact with every person you see, at every moment, you should be thinking about what can I say that may make a difference. And if you treat people as humans, then every moment can be potentially impactful, not every pill, not every symptom, not every diagnosis. I guess the core message in our conversation has been that you really have to focus on the person.I mean, the two words that have had the most impact on people that I remember over the years is “do it,” because people would come in concerned, should I do this, or should I do that? I just say “do it.” And somehow at that moment it crystallized their energy and their motivation to do something that they wanted to do. We shouldn’t be shy in trying to figure out what it is that might help someone do something they couldn’t do.The relationship is all.

Heather Clague on Psychiatry, Psychotherapy and Working with Society’s Most Marginalized Populations

Posted on by rezendevknowfully.com
Deb Kory: One of the reasons that I wanted to interview you for Psychotherapy.net is that you’re one of the only psychiatrists I know who both works in a hospital setting and also sees private clients as a psychotherapist. You are the medication-dispensing therapist that so many of my clients wish I were—though I’m so grateful not to have prescribing privileges. It would freak me out.

Since we’re releasing a video this month about working in hospitals and treatment centers, I thought you would be a great person to shed some light on that world. You are in private practice in Oakland, California, and you also you work at John George psychiatric hospital. What is your job there?
Heather Clague: John George is a public psychiatric hospital in San Leandro, California, and I’m an attending psychiatrist in the psychiatric emergency room (PES). It’s the 5150 [California law allowing involuntary psychiatric hold] receiving facility for Alameda County, so anyone who is put on a psychiatric hold in our county will come to us to be assessed for that 5150.

Our model is known as the “Alameda Model,” and it’s a way to reduce the length of stay for psychiatric patients in emergency rooms. In other counties that don’t have psychiatric emergency services like we do, people with psychiatric emergencies are taken to medical emergency rooms and then await an inpatient bed somewhere.
Methamphetamine accounts for a shocking amount of our services. Meth makes you really, really crazy.
And since there are so few psychiatric inpatient beds, they can wait days and days, often strapped to a gurney, ignored in a corner. Medical ER boarding times are significantly shorter in our county than those without a PES like ours, because as soon as the patient is medically cleared they can send the patient to us.

“We have just allowed ourselves not to see them”

DK: Dr. Heather Clague, thanks so much for taking the time to speak to me and our Psychotherapy.net readers today. Truth in advertising: you were my supervisor at Berkeley Primary Care, a community health clinic, where I did a practicum my third year of graduate school at the Wright Institute. These days we sometimes share clients and we also did improvisational theater together for a while. We’re both believers in the therapeutic value of improv
HC: Indeed.
DK: Let’s say someone is having a psychotic break and they go to a regular medical hospital and they get discharged to John George—what then happens to them?
HC: Then they come into our facility and they get an evaluation.
DK: Would you do that evaluation?
HC: I would, yes. We have a doctor-centered model where each patient will get seen by a physician once or twice, or sometimes even three times, and an assessment is made. The idea being that it should be a rapid assessment, that patients are not supposed to be held there more than 24 hours, at which point they will either be admitted to the hospital or released to the community.

But the reality is that our service can become overrun. There can be long delays and patients often still have to wait days and days to get an inpatient bed—although they are at least waiting in a psychiatric emergency room as opposed to a medical emergency room.
DK: Feeling hope and joy in this work really matters.
HC: It matters to me and I think it matters to the people that I work with. I also think there’s something about midlife where one has to reconcile reality with ideals.
DK: It’s humbling, isn’t it? Finding peace in our little slice of the pie, much smaller than we might have once hoped.
HC: But without becoming cynical.
DK: Is that why you only work there one day a week?
HC: For me it’s the threshold. Below a certain amount, I have a very good sense of gallows humor about it. The people I see who work there full time struggle a lot more with the despair and a very grim feeling that comes from working in a dysfunctional system.

The other way the system is broken is that there is a population of maybe 100, maybe up to 500 high users, people who are chronically calling 911. If they were given apartments, free taxi vouchers—just find out what they want and give it to them—it would cost vastly less than the impact that they have on the medical system. And I’m not just talking about the financial cost, but the burnout and wear-and-tear on the people who work in the system. I think there’s pretty good data on this.

If you need to go to an emergency room and you wait a long time, that is a direct result of this problem.

“The overwhelming burden of the radical not-enough-ness”

DK: You would have to retain some sense of hope to do this work. Both of us, really, but I’m quite comfortable in my cozy, private psychotherapy office, whereas you are much more in the trenches of human suffering, where I think hope is often in short supply.
HC: Or, less charitably, I think I’ve got strong internal boundaries. When I was working at Berkeley Primary Care, where you and I met, I had a population of patients that I saw as part of my ongoing caseload, and I ultimately left that environment because it was too dispiriting for me. I followed those patients long term and I think I felt too responsible for them, just this overwhelming burden of the radical not enough-ness. At least in emergency room settings what I’m supposed to do is so tiny, I can do that tiny piece really well and cheerfully and with compassion and humanity so that I don’t have solve everyone’s problems. If I can give them a moment of feeling seen as a human being, that works for me. I think it would be grandiose to suggest it really has a radically long-term effect on the patients that I see, but it allows me to sustain and feel hopeful and to enjoy what I do.
DK: That must be awfully dispiriting.
HC: Well, I can handle it when I work there one day a week.
DK: Wait, so you’re basically also a homeless shelter?
HC: We’re basically also a homeless shelter. And we are emblematic of societal dysfunction. If Alameda county would invest some money in opening up some shelters, the number of patients coming to us and medical emergency rooms would drop. There is no drop-in women’s shelter in Alameda County. There is one drop-in men’s shelter in Alameda County and it costs $5 a night, which is $150 a month, which most people can panhandle if they’ve got the wherewithal to panhandle $5 a night, but that’s a giant chunk of what General Assistance [Alameda county aid program for indigent adults and emancipated minors] gives you.
DK: Because our culture has become immune to it?
HC: Yeah, happy to ignore psychotic people. We have just allowed ourselves to not see them.

We have a large population of homeless people who use us a shelter. And almost all of them are also using drugs, but some of them will just come in and know that if they say the magic words—that they’re suicidal and hearing voices—they’ll get to spend the night. Some of them first present to the nearest medical emergency room, which amps up the expense because there are ambulances involved and there is a medical ER evaluation involved.
DK: So part of your role then is educating them about the dangers of meth?
HC: We do a little scaring them straight. “There are dangerous consequences to continued use, you could lose your teeth”—that type of thing.
DK: Is it?
HC: It’s like Altoid’s, strangely addictive.
DK: Otherwise you’re kind of on automatic pilot?
HC: Well the productivity expectations have gone up and up and up. When I started in 2001, if we had 20 people it was off the hook. Now, if we come in and there’s fewer than 50 we’re like, “easy day!” At the peak this weekend we had 86. I’m just waiting for us to hit 100. It just keeps escalating, and the population of Alameda County has not grown that much.
I think what we’re witnessing is the degradation of the mental health system—the ongoing defunding of the community mental health system and the social system.
I think what we’re witnessing is the degradation of the mental health system—the ongoing defunding of the community mental health system and the social system.

They just keep slashing money from community mental health, caseloads go up, there are fewer case managers and fewer psychiatrists. Services are getting cut or just not growing proportionate to the need.
DK: Wow. I had no idea there were so few shelters around.
HC: There are some other shelters around, but none that you can access on a drop-in basis. It’s an appalling lack of care that our county pays for through the nose, but those who pay for it are not necessarily in charge of fixing it, and so the problem doesn’t get fixed.
DK: Say more about that.
HC: It’s a high-energy place—there’s always a lot of work to get done. It’s very satisfying. There’s all these people that need to get seen and you make a lot of people happy because you send them home.
DK: Do you feel a special affinity with your colleagues there?
HC: Absolutely. The nurses and social workers who work there are fantastic. The people who survive in that environment develop certain social skills and have a certain philosophy of life—
DK: A sense of humor would be paramount.
HC: It’s so important. If we aren’t overwhelmed with patients one day, one of our social workers will say, “Well, we had a mental health outbreak today!”

Also, there’s no calls, there’s no voicemail.
DK: You get to leave it behind when you go home?
HC: Exactly. I have a very intense experience when I’m there and then when I’m done I can let it go.
DK: And do you?
HC: Yeah. I would say I do. Actually, I find it important not to let it go too quickly. Part of the problem of working there is it’s so fast-paced, it’s easy to do it a little mindlessly. So when I’m working in the hospital, it’s actually good for me to tell my husband some of the stories of the day so that I can actually take in that, “Wow, I just had a brush with someone who is having a much deeper, more complicated experience, and I got to bear witness to a small piece of a much bigger story.” It’s important to be able to sit back and reflect on what that story likely looked like.

It’s easy to let my impressions of people fall into stereotypical typologies, so it’s important to pull back from that and realize that there’s a very interesting three-dimensional person behind what looks like “just another meth addict.” This person had a mother, this person came from somewhere, they have a very specific story that brought them to this point.
DK: There’s obviously a deep level of dehumanization that has brought them to this point, and I think you’re saying that it’s difficult to yourself not become dehumanized in that environment.
HC: Exactly.
DK: So you have to find creative ways to stay present and to rehumanize these people.
HC: And oneself.

“People don’t have beds to sleep in”

DK: One thing that’s very noticeable about the Bay Area when you move here are the number of mentally ill people living on the streets. Do these folks make their way to you?
HC:
In our culture, you have to be pretty smelly or lying in the middle of the street or obviously bothering people with your lack of self-care before anyone will really take action.

There are people with chronic psychotic illnesses who become agitated or have such radically poor self-care that they come to attention of the people around them. In our culture, that has to be pretty radical—you have to be pretty smelly or lying in the middle of the street or obviously bothering people with your lack of self-care before anyone will really take action.
DK: Do you see a lot of addicts at the psych ER?
HC: Substance abuse is huge. My impressions aren’t necessarily accurate, but it feels like at least 20% of the people we see are having paranoid delusions because of methamphetamine use. Methamphetamine accounts for a shocking amount of our services; methamphetamine makes you really, really crazy.
DK: It sure does.
HC: And very aggressive.
DK: So what would you do with a meth addict who came in?
HC: Give some Ativan. Let them sleep. Feed them.
DK: Detox?
HC: We can refer to a detox facility that’s right near us, though there are shockingly few detox facilities available.

I think there should be a public health announcement in the Latino community because I see these higher functioning men working two jobs to support their families, who start using methamphetamines to increase their productivity, and then they get psychotic. I don’t think they know how dangerous it is.
DK: That people don’t have beds to sleep in and aren’t being properly treated for their addictions and poverty-related problems?
HC: People don’t have beds to sleep in, which is an easily solvable problem that would not cost that much money. It also would not cost that much money to give some intensive case management to this particular high-using group. Perhaps they are a fairly cynical, seemingly undeserving group, but it’s a funny kind of justice that would create a system like ours to punish them in the way we do. There’s this feeling that if we give those people taxi vouchers, then other people are going to learn that if they spend all their time in emergency rooms pretending to be suicidal, they’ll get taxi vouchers too. But I don’t think the population of people willing to spend all their time at the hospital pretending to be suicidal is that high.

“Well, it is fun”

DK: That’s a really good point. So if you’ve had to keep your workload down to one day to stay sane, why do you work in the psychiatric ER at all?
HC: Well, it is fun.
DK: How long is a typical stay for a patient there?
HC: I’m not sure what the average is, but it’s probably too long. It can range anywhere from a half hour—we get a quick evaluation and realize you don’t need to be there—to 18 to 36 hours. So, a night or two.

If we’re backed up on beds, or there is a placement issue, patients can stay for a number of days. That’s not ideal and everybody in the system tries to keep that from happening.
DK: Why?
HC: Because it’s a rough experience for the patients. It’s a hard place to have to hang out, especially if you’re in psychiatric distress. We have nurses and doctors rotating every shift. We are able to make some limited interventions—start medications, family meetings, have patients participate in some group therapy, but it’s primarily a facility designed to collect observations, make a decision, and move on. It’s clearly a giant step above waiting for days in a medical emergency room, but it is not equal to a good inpatient experience.
DK: Say more about the types of people you see.
HC: The 5150 is applied for danger to self—someone who is acutely suicidal; danger to others—so someone may be homicidal; and grave disability—someone who is unable to provide food, clothing, and shelter for themselves. We see people with chronic psychotic illnesses having a decompensation, people with bipolar disorder who have become manic, people who have a depressive illness and have become acutely suicidal. We’ll see people who aren’t necessarily mentally ill but they just had a breakup and have became suicidal and texted someone they were going to kill themselves.
DK: Are you only involved in the initial assessment, or are you involved in ongoing care?
HC: My general schedule is to work one day a week, so normally I would just do a one-time assessment and would see them over the course of the day if they have needs during that day. Sometimes I’ll work two days in a row and if a patient is still there then I see them again. I can do small interventions, but we’re not an inpatient service.

Bringing Grit to the Comfortable Place

DK: Without becoming cynical, right. Do you feel like your ER psychiatrist role is a separate identity from your role as a psychotherapist in your private practice Oakland?
HC: Yeah, I do.
DK: In a never-the-twain-shall-meet kind of way?
HC: Well, not entirely. I’m me. I’m the same person. But, my role is quite different. They are two ends of a spectrum: Long-term/short-term, higher-functioning/lower-functioning. But obviously the two inform each other. I think it’s good to bring some grit into the comfortable space and compassion into the gritty space. And I definitely feel like using my empathic skills in the emergency room is effective and incredibly rewarding.
DK: Speaking of which, psychiatrists are not often thought of as empathic. It’s all anecdotal, but I’ve not had many people come into my office reporting positive experiences with psychiatrists. Why do you think that is? And why don’t more psychiatrists do therapy?
HC: Well, it’s not as lucrative. If you see three medication patients per hour, you can make a lot more money than seeing one therapy patient per hour.
DK: So it’s purely financial?
HC: Well, also, in order to do learn to do therapy well, you have to feel safe and have time to empathize and mentalize, and I don’t think the medical model facilitates mentalizing.
DK: Because doctors are trying to squeeze in as many patients as possible?
HC: You’re not trying to form a model of the patient’s inner experience, you’re trying to make a diagnostic categorization and then select a medication.
If I can give them a moment of feeling seen as a human being, that works for me.
I think skillful pharmacologists obviously do need to understand the target symptoms, what the side effects are, what a particular person’s concerns about taking medication are. Obviously having empathic skills helps with prescribing medication, but I think it’s treated as icing on the cake. I think that’s true in most medical settings.
DK: When you went through UCSF Medical School, were you given any proper therapy training?
HC: UCSF did a reasonable job of training people how to communicate effectively with patients. I also went to UCSF for residency and that program was very strong in training. But I think that’s not typical for psychiatric residencies. They tend to be more biologically oriented, and I personally feel a bit skeptical about the biological approach of psychiatry. There are obviously illnesses like schizophrenia and bipolar disorder and severe depression that look like medical illnesses. They look very biological. But the human condition does not want to easily fit itself into DSM V diagnostic categories, and there’s a lot of politics behind why we shoehorn them in there.
DK: Our last interview was with Gary Greenberg, who recently wrote The Book of Woe: The DSM and the Unmaking of Psychiatry, and in it he talks a lot about how inappropriate the medical model is for maladies of the mind. How do you use the DSM? How do you view diagnosis?
HC: I hold it lightly. I have to put some code down there, and I choose from a handful of codes.
DK: Do you have a favorite?
HC: Well at the hospital, we’re allowed to use more of the bullshitty codes, the “NOS” codes. Of course, we can’t put substance abuse as a primary diagnosis because we don’t get paid.
DK: Why not?
HC: I don’t know, actually. The stigmatization of substance abuse? Insurance companies don’t want to pay for addicts who end up in the ER? Perhaps it’s viewed as an issue of volition rather than biology?
DK: Though there’s plenty of evidence for a genetic predisposition toward addiction.
HC: Well, the reason we call it volition is that we don’t have great treatments for it, so it’s blamed on the patient.

But the DSM doesn’t turn me on. I do what I have to do. Probably the biggest diagnostic question that I face is, “is this unipolar depression or bipolar depression?” I don’t want to give a bipolar patient an antidepressant and cause a manic episode, so that is an important practical diagnostic question.

Or “does this person have OCD as opposed to other forms of anxiety?” because that has treatment implications. With OCD, we’ll want to use higher doses of SSRIs and encourage therapies such as exposure and response prevention.

There is No Truth

DK: Well, if I were struggling with the Bipolar 1 or Bipolar 2 question, I’d just send them over to you to figure out.
HC: And I would tell you that there is no truth.
DK: And that would be annoying.
HC: Do you want to hear my rant about bipolar disorder?
DK: Yes, please.
HC: Bipolar got really trendy right around the time that Lamotrigine was being marketed.
DK: Which is Lamictal.
HC: Right. And the evidence for its efficacy is actually pretty weak.
Bipolar got really trendy right around the time that Lamotrigine was being marketed.
People who responded to Lamotrigine who went off of it were more likely to have a depressive relapse than people who stayed on it, but there is no control trial of people having acute depressive episodes on Lamotrigine doing better than people who took placebo. And there are all sorts of methodological issues around discontinuation studies. Even the data on lithium and Depakote is actually quite thin. And if you really want to get paranoid about it, the reproducibility of psychiatric trials is also quite weak.
DK: Because it’s too hard to control for variables? Or is it just that the nature of the mind is still so mysterious? It’s not like measuring the size of a tumor or drawing blood to see if a disease is still present.
HC: Well, we take a cluster of symptoms and we describe them and we put a label on them. Some people are probably very obsessively good at asking really detailed questions—“How many days did that last?” But I can tell you in practice I don’t have the time or the interest to go through it with that fine grain a comb. I screen for things that sound like classical bipolar symptoms, but what is ultra-rapid cycling bipolar disorder and how does it differ from the psychiatric effects of trauma? I mean, does pediatric bipolar actually exist? Kids who are beaten and raped and emotionally abused are going to have rage outbursts and sleep problems.

I saw this young man last week who was put in foster care at age 4, so who knows what kind of horror show was happening in his life before age 4. He’s been in and out of foster care. He’s been in juvenile justice since age 12, and he’s been shooting methamphetamine, and he’s telling me he has bipolar disorder. You grow up that way you’re going to be traumatized. Maybe there are people who have resiliency factors who don’t become mentally ill, but he didn’t look like he had bipolar disorder to me. He looked like someone very, very traumatized, but I’m going to giving him Zyprexa?! That just did not feel like the right solution.

The next guy who comes in, I ask, “Have you ever made a suicide attempt?”

“Oh, yeah, a bunch of times.”

“Oh, what have you done?”

“Well, I swallowed glass and I swallowed razor blades. I drank bleach.”

“When was the last time?”

“Five or six months ago.”

He’s got scars all up and down his arm and all up and down his neck. This patient did not want to talk to me about what happened to him when he was young, but in my mind, his diagnosis is trauma until proven otherwise. But this guy is not carrying a trauma diagnosis, even as a rule-out. He’s only carrying a psychotic disorder diagnosis. That just feels very wrong to me.

I’m partly on a kick because I saw Bessel van der Kolk at a conference, and what he says makes so much sense to me. He put together a diagnosis called “developmental trauma disorder,” which is obviously a trauma-based diagnosis, and one of the major cons of including developmental trauma disorder into the DSM is that it would wipe out a bunch of other diagnoses. It wipes out a lot of ADHD. It wipes out oppositional defiant disorder, borderline personality disorder, a lot of bipolar disorder.
DK: So it wipes out a lot of money?
HC: It wipes out a lot of things that people want to treat with medication. There’s compelling epigenetic research about the way that experience and trauma gets incorporated into your biology and passed on to your offspring, and it doesn’t necessarily mean that the primary solution should be to take a pill.

I’m not anti-medication. I think there’s definitely a role for pills, but the fact that psychiatry has put all of its eggs in that basket is appalling to me, especially when there’s a lot of exciting research about non-pharmacological treatments, such as EMDR, neurofeedback, hypnosis, and paradoxical motivational techiques.

How is it that we help our patients? How do we train ourselves as therapists to be highly effective on a kind of session-by-session basis? What did I do in session today that was actually effective? I think we should be collecting a lot more data, both as a profession and also individually. Our impressions are so misleading.
DK: Scott Miller has done a lot of research on what works in psychotherapy and what doesn’t. I think he reported that something like 75% of therapists think they’re better than average, which is, of course, statistically impossible.
HC: That is healthy narcissism. I would want to know what is up with the 25% that thinks they’re below average. I wouldn’t want to see them. I think it’s okay to think you’re somewhat more effective than you are.

Does pediatric bipolar actually exist? Kids who are beaten and raped and emotionally abused are going to have rage outbursts and sleep problems.
But we also need to be willing to take that confidence in ourselves to the next level, so that we can look at ourselves critically and separate out what we do that is effective from what isn’t. I was really intrigued when van der Kolk talked about doing EMDR with a patient who was very hostile toward him. He was asking the patient to be with this traumatic memory and he says, “So tell me what’s going on.” And the patient says, “It’s none of your fucking business.” And van der Kolk says, “OK, go with that,” and he completes the session and the guy tells him nothing about what he was thinking about, but at the end says, “Thank you, that was very helpful.”

So it’s not always clear how the patient liking or attaching to us predicts the kinds of changes they want or that we think they should want. I’m not saying we should encourage our patients to hate us, but I think a lot of us think we’re more effective than we are.
DK: We just recently interviewed Bessel van der Kolk as well as Francine Shapiro, the originator of EMDR, so you are in good company here. They are both big researchers and into collecting data on the efficacy of their work. Do you collect data from your clients?
HC: I’ve started to. I’m training in the David Burns TEAM model of cognitive therapy, and it asks the patient to complete a symptom rating scare before and after every session. So after every session they fill out a feedback form and they evaluate you based on how well you empathized with them, how well they felt that they were able to talk about what was important to them, whether they learned new skills and whether they’re going to do their homework, and then it lets them give a little narrative write up.

It’s very, very humbling. And it has transformed my therapy practice. You have a session you thought was great and then learn that patient didn’t think so! You’re able to come back to the person and say, “You know, it sounds like I wasn’t really getting this. Can you fill me in? How was I off track?” It’s an incredibly therapeutic moment. We’re inviting patients to criticize us and then taking that non-defensively. How many people have that in their lives where they get to actually say to someone, “that kind of sucked,” and to have that received that lovingly and non-defensively?
DK: And with curiosity.
HC: It’s incredibly hard to do. And we’re only human. But I think that having the right kind of training can make it possible.
There is a lot of narcissistic support built into our field for embracing failure.
Allowing ourselves as therapists to really take pride in our failures is what allows us to be non-defensive and to receive critical feedback from patients in an open-hearted way. For example, it turns out my grandparents were right, I really do talk too fast. I’ve heard that on enough feedback forms. That’s humbling, but at least I know I have that tendency, and when it comes up I can validate the patient’s experience. And actually, now that I think about it, I haven’t gotten that feedback as much lately, so maybe I’m actually doing better at slowing down!

To Prescribe or Not to Prescribe?

DK: Do you generally try to do psychotherapy first for a while before prescribing?
HC: So much depends on what the patient comes in expecting and wanting. It’s really interesting, because some people are very clear: “I don’t have the time and energy for CBT. I want a relatively straightforward, easy solution to my chronic anxiety, and I’m willing to take the risks that come from medication. And I only have to see you every six months if I’m stable.” And that works for me. CBT is hard work. Actually, most psychotherapy is hard work and that doesn’t fit for everybody.

And then other people feel like, “I don’t want to take a pill. I don’t want to take medication. I don’t want to be labeled and stigmatized and reduced to that. I want to explore and understand.” It’s a tremendous privilege as a clinician to be able to work with people in such a broad way. The danger is that I’m a little jack-of-all-trades, master-of-none. I’m not the most hotshot psychopharmacologist. I’m not up to date on all the latest meds. But I’m really good at SSRIs.
DK: Speaking of SSRIs, given that they work slightly better than placebo, do you tend to psychoeducate people about that, about all the risk, the fact that we don’t even really know why they work?
HC: No. I don’t. Because I want to maximize the placebo response. I give them every testimonial I can. Because they’re not just getting the pill, they’re getting me prescribing the pill. They’re getting the experience of having a relationship with me and so to whatever extent taking that pill is internalizing me, I want that to be a positive experience.

Now, I’m not going to shine them on and say that SSRIs always work or are completely benign, but as drugs go—certainly compared to the mood stabilizers or heavens, antipsychotic medications—I think they’re relatively benign. They’re not so benign for people who might be bipolar, since they can bring on severe agitation or even manic episodes, so I have to be careful there, but otherwise they are relatively benign.
DK: If somebody is clearly suffering with chronic depression, they are in therapy, and they’re open to getting pharmacological help, how many SSRIs are you willing to try on a person before you give up?
HC: The data shows that the chance of it working goes down with every trial. But, again, they’re not getting a pill, they’re getting the experience of paying a fair amount of money to come sit in my nice office, to sit across from me, and have me listen to their story, and then to have a conversation with me about what it means to take medication. And then to have customized dosing.
DK: So it may be that they’re getting the therapeutic effect of seeing you rather than from the pill.
HC: Right. I had a client some time ago with a lot of trauma who had bad experiences with antidepressants, and we shifted him to Prozac and it was going well and I remember him saying to me in session that he was feeling much better, but also sometimes feeling really sad and that it was scary for him.
The expectations of psychiatrists are so low….I get a lot of credit for having kind of average social skills.
I was able to tell him that the fact that the sadness came up right when he was feeling better made me think that maybe his body was realizing it was safe to feel his feelings. I pointed out that he’d had a lot of trauma in his life and lives in a high-pressure culture with a high-pressure career as a high functioning person and that it’s easy to become phobic about feeling sad. And I said, “What do you think about the idea of just allowing the sadness?” And he was so visibly relieved by that.

I think there’s something very powerful about having your prescriber license your sadness instead of pathologizing it. Of course your therapist can do the same thing, but some of what I do is help support therapists whose clients I share. They want to know that they’ve done everything they can in the therapy setting and I can validate that and help them feel less alone in their treatments.
DK: It makes everybody feel more confident, including the clients who feel like, “I have a team working with me.”
HC: Which is why the current model of overburdened, non-psychologically-oriented psychiatrists handing out pills and not calling back therapists probably isn’t the most effective. The expectations of psychiatrists are so low.
DK: No kidding.
HC: I can walk on water because I return phone calls. I get a lot of credit for having kind of average social skills. Very privileged place for me to be in. I will not complain.
DK: Because you’re not a complete weirdo.
HC: There are a lot of very weird therapists out there, too, though.
DK: We are a strange subculture. Or maybe everyone is strange but the standards are higher for us because we’re supposed to be helping people with problems in living?
HC: Well, when you’re vulnerable and need help, you’re really sensitive to the weirdness.
DK: Well, on that note, I want to thank your only modestly weird self for participating in this interview.
HC: It’s been a pleasure.

John Sommers-Flanagan on Clinical Interviewing and the Highly Unmotivated Client

Posted on by rezendevknowfully.com

When In Doubt, Act Like Carl Rogers

Victor Yalom: You and your wife, Rita Sommers-Flanagan, are well known in the field for your work in Clinical Interviewing, and we are delighted to be releasing your video on this topic concurrently with this interview, but before we get into that, I know you’ve also done work with mandated or otherwise unlikely and unwilling clients. Much that’s written about therapy implicitly assumes that the client is there willingly, but in many settings, clients are overtly coerced into coming by courts or institutions, or they’re strongly nudged into treatment by their parents or spouses. How do you work with these clients?
John Sommers-Flanagan, PhD: A lot of my thinking in this area sprang from the work I did in private practice, primarily with challenging teenagers. As you can imagine, many of them did not want to be in the room with me, so the challenge was, “How do I engage this person?”

I have a vivid memory of a young man who spent 30 minutes just saying, “fuck you” to me. I remember trying to go through every strategy I could think of. But probably the best of all was just to try to be like Carl Rogers and listen in an accepting way to that particular message over and over again.
VY: Did you literally reflect it back to him like Carl did, verbatim?
JSF: Well, Carl had a case known as, “The Silent Young Man,” where he’s treating this young man who doesn’t want to speak at all, and I think I was trying to channel him in that situation. So I started off by saying things like, “Well, it sounds like all of a sudden you’re pretty angry with me.” And all I got was, “Fuck You.” Then I was saying things like, “It’s clear that there was something I did or said that offended you and I’m not sure what it was.” Then I did a little self-disclosure. After about 15 or 20 minutes, he was still just saying, “fuck you,” but he started singing it to me as 15-year olds might be inclined to do. That went on for 10 minutes and I’m doing my Carl Rogers impersonation, “Well, you sound like you’re not happy, but even though you’re still swearing at me, you’re not angry any more. Now you’re happy and singing it to me.”
What happened next was really interesting. Keep in mind this was not a first session, it was a sixth, maybe seventh session. When he came in the next week, he sat down in the same chair and looked at me. I was anticipating more anger and more resistance, but the first words that he said were, “I’m just wondering, how would you feel if you were to adopt me?” Which was kind of a shocking change, and actually much more difficult than, “fuck you.”
VY: What did you say?
JSF: Well, he said it in this kind of off-handed way, and I just decided at that moment in time that I should try to be genuine and I responded with some disclosure about feeling a little nervous because this was a young man who had a pretty significant history of violence. I said, “I think I would feel pretty nervous about some of the ways that you’ve been with people.” And that launched us into a different discussion.
For me, it sort of captured how important it is to be, as Marsha Linehan might say, “radically accepting of what the client brings into the room.” Or as Rogers would say, “You just kind of work with what you’re getting.” It seemed to help us go deeper and it facilitated exploration and more engagement.

“You sound like a stupid shrink and I punched my last therapist”

VY: So one thing I get from this nice story is the underlying message of really hanging in there with a client, even in an extreme case where they’re coming in and swearing at you perhaps for the whole session or half a session. Really being there and meeting them head on, and being as genuine as you can.
JSF: Absolutely. A more common example is one that I get all the time with some of the difficult young adults I work with now. A 20-year old very recently came into therapy and I said something like, “Welcome to therapy, how can I help you?” And he says, “You sound like a stupid shrink and I punched my last therapist.”
This again captures a lot of the pushing and testing that happens with reluctant clients. I said, “Well, thank you very much for telling me that. I would never want to say anything that would lead you to punch me, so, how about if we decide that if I say anything that makes you want to punch me, you just tell me and I’ll not to say it anymore?”And the kid sat back and said, “Wow. Okay. That’s alright with me.”

VY: How do you conceptualize uncooperative or unwilling clients?
JSF: Well, there are few different dimensions. The first is how they’re referred. They’re often referred by a probation officer or principal, or the parents bring in someone or someone is abusing substances and has been given an ultimatum, or a spouse insists on some kind of counseling and so they come sort of unwillingly into the room.
Then there is the way that their resistance manifests in the room. Sometimes it manifests in silence. “I’m not going to talk to you and you can’t make me.” My standard response to that is what I think people have referred to as a concession where I say, “You are absolutely right. I cannot make you talk about anything in here. I especially can’t make you talk about anything you don’t want to talk about.” With teenagers, I will say that and then I’ll pause and I’ll say, “Well what do you want to talk about?” It’s like they need to posture by saying that they won’t talk, and when I concede that they’re right, that they do have control over themselves, then they tend to respond.
Other times, as I’ve just talked about, resistance is much more aggressive. I remember an older man who said, “We might get in a fight in this meeting.” That’s a much more aggressive kind of resisting the initial contact.
And, lastly, there are some people who resist through externalizing, as in, “the problem is with my school,” or “It’s with my spouse,” “it’s with work,” “it’s with everyone but me.” The challenge then is to listen empathically without getting too frustrated, because if I get frustrated and accuse the person of externalizing, oftentimes it just makes them more defensive. Those are three different categories I can think of off the top of my head: the very silent client, the very aggressive, and the very externalizing client who has a lot of trouble taking any initial responsibility for his or her problems.
VY: So aside from acceptance, empathy, and trying to really be there authentically, what are some other key principals for the therapists working with these kinds of clients?
JSF: I don’t know if you remember Mary Cover Jones, who did some of the early work with John Watson on helping young children desensitize their fears, but she said, “We have two means through which we can help decondition people. One is counter conditioning, where you have some kind of positive stimulus that you pair with the anxiety-provoking stimulus. And the other one is through participant modeling.” She wrote about that in 1924, and it was pretty amazing stuff at the time.
So I have started to reconceptualize people who are resistant to therapy as people who are anxious about the situation. I think, “How do I produce an environment that is going to counter-condition anxiety? What’s in my environment that might help people feel more comfortable and less anxious?” It’s another principal I’m often thinking of in a clinical situation.
VY: I can’t help but note that you’re pleasantly eclectic. You’re combining the epitome of humanism, the person-centered approach of Carl Rogers, with hardcore behaviorism.
JSF: I don’t consider myself a behaviorist, but I also think that if we don’t understand behavioral principals of reinforcement and classical conditioning, we can inadvertently do all the wrong things.
Foundationally, I want to have an office, I want to have a wardrobe, I want to have a way of being with clients that is going to counter-condition any anxiety that the person might feel.
I want to have an office, I want to have a wardrobe, I want to have a way of being with clients that is going to counter-condition any anxiety that the person might feel. Mary Cover Jones used cookies with children, and when I work with teenagers, I absolutely use food. I will have some food, fruit snacks or something nutritional in the room that I can offer, and in some ways I’m thinking absolutely behaviorally at that point. And I’m also thinking relationally—it’s about having a supportive, mutually collaborative relationship. We’re working together.
VY: Can you say a little more what you mean by examples of counter-conditioning anxiety?
JSF: Well, I was just looking through Skype into your space and you have some fabulous artwork. And I think it’s important to have a room that has comforting, pleasant artwork and other kinds of symbols that will help put people at ease. And if you’re working with LGBTQ people, there should be some kind of symbolic communication that you are welcoming those people into your office.
Same thing here in Montana. We work a lot with the Native American population, and it’s really important to have some sensitivity and representation in our office of that sensitivity.
When working with younger clients, the same thing applies. I was supervising a young man who had a 16-year-old boy client who said, “I will never speak to you about anything important in my life, period.” We knew from his referral info that he had been the person to discover his father had hanged himself, so he had some terrible, complex, traumatic grief.
My supervisee said, “What am I going to do?” And I said, “Take the checkers. Take backgammon. Take some games. Take some clay. Take some things into the room. And don’t force him to talk. Just be with him. Play.”
They played for three sessions, just played backgammon. And at the end of the third session, the client looked at the counselor and said, “Well, should we keep seeing each other? Because you said I only needed to come three times.”
And the counselor said, “Yeah, I think we should keep going.”
And the client said, “Well, okay then,” and he pushed the backgammon set aside and starting talking. To me it seemed like a great example of counter-conditioning. They used playing games as the stimulus that was pleasant and non-threatening.
VY: And participant modeling?
JSF: That’s really important, although obviously you can’t really have other people in the room modeling, so the therapist is the model, and is modeling comfort in all things. Comfort when the client says, “I’m feeling suicidal.” Comfort when the client says, “I want to punch you in the nose.” The response is to appreciate those disclosures, instead of being frightened by them. Being frightened by the client’s disclosures is going to feed the anxiety, instead of counter-condition it or instead of modeling, “We can handle this. We can handle this together. It’s best if we do talk about all these things, even the disturbing things that you bring into the room.”
VY: How do you help students, beginning therapists, achieve that? And, how do you balance that portrayal of comfort with authenticity when, in fact, beginning therapists may not feel at all comfortable?
JSF: That’s a great question, and it’s one of the challenges because you want the therapist to be genuine, and yet at the same time you want them to be comfortable. And often those two things are a little bit mutually exclusive.
But I think first of all, information helps. It’s helpful to our trainees and interns and young therapists to really understand and believe that, for example, suicidal ideation is not deviant. It’s not pathology. It’s an expression of distress, and if people don’t tell you about their suicidal ideation, then they are keeping it inside, and they’re not sharing their personal private experience of distress.

I try to do a lot of education around that, whether it’s suicidal or homicidal ideation or trauma or whatever it is that clients might talk about. It’s really important for young therapists to know if they don’t talk about it, we’ll never have a chance to help them with those legitimate, real thoughts and experiences that they’re having.

And the other big piece is practice, practice, practice.

VY: How do you practice these things?
JSF: To give an example, a lot our students initially do suicide assessment interviews, and they’ll say to their role-play client, “Have you thought about hurting yourself?” I’ll interrupt and say, “Okay, now use the word ‘suicide.’” Now say, “Have you thought about killing yourself?” I’m wanting them to get comfortable with the words and to practice using those words so that they aren’t so terribly frightening.
I remember supervising a new student who was conducting an initial assessment, and about half-way through the 30-minute interview, his client says, “I used to have a terrible addiction problem, and one of the things that really has helped me with my recovery is cycling. I’m an avid cycler and it’s really helped me with my drug and alcohol problems.”
At which point, he freezes in panic and says, “So what kind of bike do you have?”
I stopped the tape and said, “Hey, what was going on?” He says, “I was scared, I didn’t want to open things up.”
I said, “Well she did. She opened it up. She shared with you that she had an addiction problem, that she was in recovery, and that she had a method that really is helpful to her. So it would be perfectly natural for you to then use your good active listening skills and ask an open question or do a paraphrase or reflection of feeling, and to stay focused on the target, which was addiction recovery coping, instead of asking what kind of bike she had.”
So it’s a combination of offering encouragement, practice, and feedback.
VY: In addition to behavioral principles and humanist principles, what other theories or principles do you draw from?
JSF: Well, in the psychodynamic realm, I’m thinking of Edward Borden’s work on the working alliance and his effort to generalize it from the psychoanalytic frame to other frames. And the emotional bond between therapist and client, which Anna Freud wrote about initially. We really try to facilitate that.
We also engage in collaborative work toward goal consensus between therapist and client, and it could be that we agree that the therapeutic task involves free association and interpretation and working through. Or it could be a therapeutic task that involves exposure and a real behavior modification approach.

Clinical Interviewing

VY: You and your wife Rita Sommers-Flanagan have written a comprehensive and widely-used textbook entitled, Clinical Interviewing, about the initial stage of therapy, where you’ve examined and broken down in great detail all the aspects that those first few sessions. Can you explain what you mean by “clinical interviewing?”
JSF: It’s a term that originally referred to the initial psychiatric interview, which has a lot of assessment in it. So it refers to that initial contact. But as we have grown, we’ve come to see it as not just an initial contact. In some ways, every contact is a clinical interview in that every contact involves this sort of two-headed goal of assessment and helping. And then the third component is the working alliance, or the therapeutic relationship.
As we know, assessments in a clinical interview produce more valid data if we have a good working or therapeutic relationship. The evidence is very clear that therapy outcomes are more positive if we have a positive emotional bond, and we’re working collaboratively on goals and tasks. So I see the therapeutic relationship as central to the assessment and the helping dimension of the clinical interview.
VY: It’s the beginning phase of therapy.
JSF: Yes.
VY: In reading your text and also in viewing the video we’re releasing conjointly with this interview, you really emphasize the importance of the therapeutic relationship or rapport-building as an integral part of that initial contact.
JSF: Right. Even if you’re doing something as straightforward as a structured diagnostic interview, or a mental status examination, you really want to engage in a therapeutic way with the patient or the client.
VY: Because you’re not going to get much information or accurate information if they don’t feel like you’re on their side?
JSF: Absolutely. It’s about establishing trust and helping people to be open. I’m very familiar with your father’s work, and in The Gift of Therapy, he writes, “In recent and initial interviews, this inquiry into the typical day allowed me to learn of activities I might not otherwise have known for months.
Even if you’re doing something as straightforward as a structured diagnostic interview, or a mental status examination, you really want to engage in a therapeutic way with the patient or the client.
A few hours a day of computer solitaire, three hours a night in Internet sex chat rooms under a different identity, massive procrastination at work, ensuing shame. A daily schedule so demanding that I was exhausted listening to it.”
And he goes on and on about these disclosures that he was able to get by asking a simple question, “Tell me about your usual day.” To me, that’s a great example of how rich the assessment data can be with a simple question, if you have a positive rapport and therapeutic relationship.
VY: So it seems like a fundamental balancing act that you’re always dealing with is how do you balance getting sufficient information—particularly if you work for an agency where forms are a part of the process—while establishing sufficient rapport. Because if they don’t come back for a second session, the treatment is surely a failure.
JSF: Right, how do we balance the information-gathering task that we might have for our agency with the relationship task? And how do we do that with culturally diverse clients?
One of the things we try to do in the Clinical Interviewing book is to go into detail—with an outline and structure—of different kinds of initial clinical interviews, including the intake and the mental status exam, suicide assessment, diagnostic interviewing, and other kinds of interviews, yet emphasizing throughout the importance of the relationship.
So if I have a checklist that my clinic is requiring me to fill out, I would say to the client, “This part of our task today. I am supposed to ask these questions and record your answers, but I also want to hear from you in your own words things that you’re experiencing. So I’ll try to balance that with you.” And I’ll actually show them the questionnaire or the checklist.
VY: So be transparent.
JSF: Be transparent. Absolutely.

Multicultural Competence and Moving Beyond Your Comfort Zone

VY: You mentioned different cultures. What are some particular considerations that come to mind about that?
JSF: Well, some of the principals that come to mind for me involve respect for the native culture here in Montana and throughout the U.S. I think respect is a core part of beginning any relationship. And I think respect involves understanding and being able to pronounce the names of various tribes, asking very gently and respectfully about tribal affiliation here in Montana. I will sometimes say that I know some people from, say, the Crow tribe who have been students in our program. Even if they don’t know the particular students, it can be helpful to hear that I have had contact with somebody who’s got the same tribal affiliation as them.
Cultural competence also means that we take the time to read and study about working with Latino or Latina clients. It also involves using what Stanley Sue referred to as “dynamic sizing” and “scientific mindedness,” where we try to figure out, “Does this cultural generality apply to the specific cultural being in my office?” That’s a difficult but very important thing to determine.
VY: Just a couple weeks ago I had the privilege of interviewing Stanley Sue’s brother, Derald Wing Sue, on multi-cultural issues. One of the things he emphasized was really getting outside of your comfort zone and getting to know these other cultures on a more than superficial level.
JSF: Another thing he really emphasizes is the question that can’t help but be in the back of the mind of many minority clients: “Is this therapist the kind of person who will oppress me in ways that other people in the dominant culture have oppressed me and my family, my tribe, or my culture?”
One of the remedies that he and others have talked about is for therapists to be more transparent, and use a little more self-disclosure. Because without doing that, there’s just no good evidence that we’re not the oppressor or the “downpressor” as some Jamaicans would say.
So diving into the culture, getting to know it on more than a surface level, and then being able to use some of the principals that Stanley and Derald Wing Sue have articulated well is essential. It makes things much more complicated and much more rewarding.

Intake Essentials

VY: There are many models of how that initial client contact occurs—from a brief telephone intake to, in certain settings like substance abuse or mental health treatment centers, having a designated intake worker who passes on the client to interns or therapists. Do you have a general recommendation or sense of what the best practices are for the initial intake?
JSF: Well, in agencies where there is a handoff from an intake worker to other therapists, it can be difficult to maintain the therapeutic connection. In that case the initial session becomes much more about clinical assessment than initiating therapy.
Constance Fischer and Stephen Finn have written about these kinds of therapeutic assessments since at least the late 1970’s, and they suggest complete transparency through the process. “Here’s how things work in this agency.
This will be my only session with you. I would like to work longer with you, but what I’m going to be thinking about during our time together is who might be the best match for you for ongoing counseling or psychotherapy.”
Without that transparency we run the risk of alienating the client—leaving them feeling like, “Oh, man, I have to go through all this again with another person next week?”
VY: It’s hard enough for people to get into treatment in the first place. As I often say to clients, “People are not usually waiting in line to get the therapy.” It often takes people years.
JSF: Right, and when we put another hurdle there it makes it even more difficult. So it’s important to explain the hurdles and let them know how best to get over the next hurdle.
VY: Is your general sense that it’s better not to have a separate person doing the intake if possible?
JSF: I think it’s better to have the same person do the intake and then continue with therapy. There are, of course, exceptions to that. If you have someone who is not well-trained in substance abuse therapy, and then it becomes clear in the first intake session that this person has an active substance abuse problem, transferring the person to a therapist or counselor who has that experience would be a better fit.
And you can just explain that to the client, although oftentimes the client will still say, “Oh, but I’d rather work with you.” But as long as you have a good rationale, you can make that transition relatively easily. So, yes, it’s best to have the same person do the intake and then continue with the therapy, except in situations where there’s a clear rationale to do otherwise.

Treatment Planning

VY: What are your thoughts about treatment planning? There’s a lot of emphasis on that in many agencies. Do you think that’s something that actually can be done with any specificity? So often someone comes in thinking they’re here to work on X, and six weeks later, you’re really working more on Y. So at times I wonder who the treatment planning process is really serving. Is it really serving the client, or is it serving some agency needs, some funding needs, or the anxiety of the therapist?
JSF: I remember an old supervisor saying to a group of us, “We’re not technicians. We can’t really lay out a protocol for exactly how to act with every client. Every client’s unique, so we need to go deeper than that. We’re professionals, and we bring both art and science into the room.”
I think it’s important to blend the two.
I’m not a big fan of cookie cutter treatment plans. But I am a fan of looking at the plan, talking with the client about what our plan is, and being somewhat explicit and collaborative in that process. I see it as a kind of dialectic—it’s a little bit cookie cutter in that it doesn’t bring in much of the individuality of the client but it does have some important information for us. From there we can dive into the unique qualities of the client and their experiences.
As an example, let’s just say you have a client who’s impulsive. We know that there are certain kinds of treatments that we might use with someone who is diagnosed with ADHD who is impulsive, where those impulsive behaviors are getting him or her in trouble. It’s good to know about CBT and other kinds of therapies that might help with impulsivity. But it’s also really important to get into the mind and, in some sense, the body of that individual client to understand what’s going on with that person.
But knowing that there are probably triggers that increase and decrease impulsivity is something you’d want to work on with a CBT treatment plan. It can help focus the questioning, even if you’re working from an existential perspective.

“Evidence-Based” Treatment

VY: As you’re a professor at the University of Montana, and actively involved in training students, I’m wondering what your thoughts are about the major trend towards “evidence-based” treatment? There are a lot of leading figures in the field who are critiquing this trend. John Norcross talks about evidence-based relationships, since research actually shows that most of the positive outcomes in therapy are based on the relationships and not on this or that technique or procedure. Are you pressured by accrediting agencies to teach evidence-based treatments? What have your experiences been in this regard?
JSF: Yes, there is a lot of pressure to incorporate “evidence-based,” or “empirically-supported treatments.” When you look at Norcross’ work, you have to shake your head and wonder why we focus so much on technical procedures and evidence-based treatments. The science just really isn’t there. There are studies done that show X or Y treatment is effective and, therefore, it becomes evidence-based. And yet there’s a mountain of evidence saying otherwise, that it’s not the specific protocols that make a positive treatment outcome.
There are these voices in the wilderness, like Norcross, crying out about this, but there’s still this inexorable trend towards requiring these evidence-based treatments in training students and in various government agencies, for example.
The cynical side of me would say it’s about trying to get our share of the healthcare dollars. Shaping ourselves to be in the medical model, since there are empirically-supported medical treatments. Of course, there is some real scientific evidence that we should be aware of when working with our clients. We should be, because we’re professionals in this area. Like Norcross writes about, there are evidence-based relationship principals that account for positive outcomes and so we need to look at those, and we need to emphasize those more than the technical procedures. There are evidence-based relationship principals that account for positive outcomes and so we need to look at those, and we need to emphasize those more than the technical procedures.
But we shouldn’t ignore all technical procedures because, even Carl Rogers would say, “If the technique arises spontaneously out of a particular place where you are in the counseling process, then it may be appropriate.”
VY: In wrapping up, any advice you would give for students or early career therapists just starting out?
JSF: I think my biggest advice these days is to focus on balance: The balance between the science and the art, the balance between the relationship and assessment and diagnosis. We need some diagnostic information in many real world situations, but we should not try to get that at the risk of damaging the therapeutic relationship. The impulse is for people to go one direction or the other. I was at a workshop one time where a woman referred to people as science “fundamentalists,” which I thought was a very apt description of some people. They have this allegiance to the paradigm of modernist science, and that’s the only way truth is known.
Then there are people who are much more touchy-feely and go with the flow. My general advice would be, if you’re more of a touchy-feely person, you really still need to learn the science. You still need to read the clinical interviewing text and understand the content that is our professional foundation. And if you’re more inclined toward scientific fundamentalism, you need to get out of that box and try to learn from the other side of the dialectic, which is the relational, emotional side of things that happen in the therapy office.

Advice for the Late-Career Therapist

VY: So let’s use mid- or later-career therapists as an example. By that time in their careers, many have migrated to private practice and have gotten very comfortable in their own ways of being with clients. In many ways that’s a good thing—it’s part of the career progression to take everything you’ve learned along the way and integrate that into who you are as a person. But one drawback I see is the possibility of just jumping into therapy with any client who walks in your office—assuming they’re a good fit for you—without maybe doing a proper assessment. And then they find out six months down the road that the client has a drinking issue that they hadn’t disclosed before. Any advice for these later-career therapists?
JSF: Yes. I’m not in full-time private practice right now but I have friends who see 35 people a week, and are doing the kind of thing you’re talking about.
It’s so easy for us to get into a little niche where we do it our way, and we’re no longer open to other ways of thinking. I’d say it’s really important to keep stretching yourself, to keep reading, to keep going to professional workshops, because we can do things wrong for years and think that we’re actually being successful.
Scott Miller is emphasizing it now more than anyone else–but it’s incredibly important to get systematic feedback from our clients so that we can get a sense whether we’re on the right track with each individual client.
Even though we sometimes can convince ourselves that we’re incredibly intuitive and we can, therefore, launch into therapy immediately, there is some research that suggests that negative outcomes correlate with inadequate assessment. So we do need to step back and do a little formal assessment here and there, even though, as experienced practitioners, we might think, “I know what to do here. This is not a problem.”
Instead, step back and to say, “Let’s do a little bit of assessment here so we can work together to make sure that we’re on the right track.” In other words, mid-therapy adjustments and assessments to make sure that we are helping our clients as effectively as possible.
VY: A final question: What’s your growing edge right now as a teacher and practitioner?
JSF: I have several growing edges. One growing edge that’s pretty constant for me is working toward greater cultural sensitivity, and being able to know more deeply about people who come from diverse minority kinds of backgrounds.
Another growing edge for me is the whole idea of mindfulness and how to incorporate that into some of the more traditional ways that I was taught to do psychotherapy.
I think the other growing edge for me is kind of a growing foundation. The person-centered principals for me have always been foundational and I find myself sometimes really wanting to go back to those. I can see myself in future months or years going to some trainings to get even better at the things that I think are my basic foundational skills.
VY: I often have the opportunity to review some old videos that we’ve acquired or produced and just recently watched the first video produced with James Bugental, a human-centered existential therapist. I’ve probably seen that video 20 times and I still appreciate it, perhaps on an even deeper level.Well, I want to thank you for taking the time to talk with us today.

JSF: Thank you very much, Victor. I very much appreciate your work and the fact that you have dedicated a lot of your life to making the work of other great therapists accessible to all of us.