Up to 40% of new psychotherapy clients never come back for a second session.

While many therapists would consider such single session clients “failures,” but the fact is that given how often it happens, they must provide people with some benefit or relief in some percentage of those cases. (Others likely just find the therapy experience not helpful to their needs, not what they expected, or disliked the particular therapist they saw.)

The APA’s Monitor on Psychology this month has an article on phenomenon, with helpful tips to therapists on how to make the most of a single session, including the finding that such single sessions can be helpful to people:

Indeed, as-yet-unpublished research by a team of psychologists from the Department of Veterans Affairs, found a single, 60-minute session can even help people with serious mental illness. After just one “motivational interview,” participants were significantly more likely to enter a vocational rehabilitation program, and they stayed in the program for three months longer than a control group, says Lisa Mueller, PhD, a research associate on the study, led by psychologist Charles Drebing, PhD.

Most people feel very relieved after their first session of psychotherapy. And for many, that’s sufficient. It’s a cathartic experience for them and they take something away from the chance to bare their souls to another person. Even if they never return.

The four tips offered in the article include:

• Zero in on a single problem. By focusing on a single issue of most concern to the person and the reason that brought them into therapy, a therapist may be able to help provide the person with some guidance on how to best approach the issue.
• Unearth hidden resources. The article notes that most people might have the tools and resources necessary to fix the big issue in their life. They may just need a little help finding them.
• Don’t cajole. It’s important for a therapist to show a person they are on their side, and help them explore the pros and cons of a situation. You can’t force change to happen quickly, so a therapist shouldn’t bother to try.
• Plan for the future. A therapist can be helpful if they provide the person with additional resources and direction on where to learn more about their problems on their own. One simple exercise taught in a single session can be helpful to a person to practice on their own, such as a relaxation tip or reframing of irrational thoughts.

I’d add a fifth tip — Never assume your new patient is coming back. If you treat every new patient as a possible single session intervention, you may be surprised to find how powerful and helpful that one session can be for people.

Read the full article at the American Psychological Association: Make the most of one session

Worse yet, the vast majority of people who are diagnosed with a disorder that may have a genetic component do not carry the genes these tests look for. That means that the test could come back negative, and you could still have the disorder. So what’s the point then?

Someday, genetic testing may prove useful in mental disorder diagnosis and prevention. But that day is still many years — and perhaps even decades — away. Don’t get suckered in by these companies looking to prey on people’s misunderstanding of these tests and the stigma associated with these disorders.

Read the full article at the Philadelphia Inquirer: A $400 test to evaluate your chances of bipolar disorder?

You can’t be anonymous online if you…

1. Join virtually any social network (since, by their very nature, they encourage you to share as much information as possible with their services and others through their website).

2. Post a photo of yourself anywhere online (or on any social network). Photos are readily identifiable and anyone who’s ever thought, “No one will ever see this,” are usually disappointed at how incredibly wrong they are when their boss/boyfriend/girlfriend/spouse/parent gets an emailed copy of it.

3. Share key identifying information about yourself, including (but not limited to): where you work or go to school; your hometown; where you live now; your neighborhood; your age; your favorite band; your favorite hobbies; the people you know; etc. While any one single piece of information is unlikely to identify you (outside of your name, phone number, email address or social security number), a combination of pieces of information (which most people share haphazardly, over time) can often paint a picture of your identity.

4. Use the same pseudonym or email address as your identity on multiple communities or social networks. People are amazed at how easy it is to track down their online history through this simple piece of data (which is very often unique).

5. Sign a guestbook or add a Facebook application to your profile. As the BBC so easily demonstrated last week (link to BBC video which auto-plays), once you give away access to your profile information to a Facebook application, it can be gone for good (as well as all of your friends’ profiles too!). While Facebook pays lip service to being able to spot such malicious applications, the truth is that there are far more people incentivized to create these kinds of applications than there are people who can stop them from proliferating.

As the head of Sun, Scott McNealy said nearly a decade ago, “You have zero privacy anyway. Get over it.”

While that may be true, you’re better off if you don’t delude yourself that you have any inkling of privacy when you join a social network (especially those that claim they offer “anonymous” social groups).

Your privacy online is fleeting and fragile. Take it from there…

Don’t get me wrong — most mental health professionals take their time, explore rule-out diagnoses, and always seek to ensure the person in front of them really fits the diagnostic picture for a given disorder. But as we reported today, bipolar disorder may be overdiagnosed in real life practice, where nearly half those initially diagnosed with bipolar disorder didn’t actually meet the criteria for that diagnosis.

Imagine any other scientific field where you can be wrong half the time and still be considered “scientific” in any sense of the world.

Via Philip over at Furious Seasons today, I learned of one college student’s mental health journey, published in the college newspaper as, To hell and back. While long, it’s an interesting story of a college student’s experience with various psychiatrists and grappling with mental health issues while in college. And it shows just how badly professionals can work to misdiagnose an individual, over and over again. (Keeping in mind, of course, that this is just one side of the story; the story the professionals mentioned in the article may tell of this person might paint a very different picture.)

Diagnosis is part art, part science. While there are structured clinical interviews that can take much of the “art” and guess-work out of diagnosis, such structured interviews are rarely used in everyday clinical practice because they take too much time (and one might argue, too much effort on both the clinician’s and patient’s parts). So most clinicians rely on their experience and training to diagnose. After seeing dozens or hundreds of people with depression, a professional can start to feel they can spot “depression” a mile away.

But an initial interview with a person who is seeking mental health services should take time and patience. In an outpatient setting, it is typically about 75 to 90 minutes in length, and this is on purpose. It is an information-gathering session and one that, if rushed, much can be lost in obtaining a balanced picture of the person’s life. By the end of that first session, most experienced clinicians have a pretty good sense of what might be going on with the client and can reliably formulate an initial diagnosis.

Sometimes, a professional will defer a diagnosis because the picture is still not clear. It may take another session or two before they feel like they have enough information to provide an accurate diagnostic label. Other professionals don’t care as much how reliable or accurate their diagnosis is, feeling either the actual diagnosis isn’t all that important (oblivious to how such labels will follow the person around for the rest of their lives on their medical charts), or that it’s “good enough” for the patient’s current complaints.

In hospital settings, such an interview can be rushed and completed in as little as 20 minutes. Professionals feel they can do an adequate job in such a short period of time, but likely fail miserably in their ability to produce reliable and accurate diagnoses for their patients.

Sadly, I don’t think that Thor Nystrom’s college story is all that unique. And his struggle to be accurately diagnosed shows a not uncommon failing within our hodge-podge mental health system. This struggle is typical when multiple professionals get involved in a single person’s life, all offering their own unique view of the patient’s issues. And all rarely agreeing on what the “real” diagnosis or problem is.

There’s no clear solution here, outside of mandating and instituting structured clinical interviews for all. But I doubt that will happen, even when research shows our current diagnostic procedures are failing miserably, because professionals (and insurers who pay for all of this) are invested in the current system.

No matter how broken it may be.

Then the researchers looked at the rates of psychiatric hospitalizations of either parents between the two groups.

The researchers found that mothers and fathers diagnosed with schizophrenia were about twice as likely to have a child diagnosed with autism. They also found higher rates of depression and personality disorders among mothers, but not fathers.

Knowing whether autism might be more prevalent in families with a history of psychiatric problems could better inform future prevention efforts. Whether the link is passed via the environment (e.g., through the family child-rearing environment) or through genetics, or a combination of the two.

Psychologists have shown that human personalities can be classified along five key dimensions: agreeableness, conscientiousness, extroversion, neuroticism, and openness to experience. And each of these dimensions has been found to affect key life outcomes from life expectancy and divorce to political ideology, job choices and performance, and innovation and creativity.

These are referred to as the “Big Five” personality factors by psychologists and can generally be measured by a test called the NEO-FFI, NEO PI-R, or something along those lines (here’s an online version, but it takes forever to complete). Wikipedia’s description of each of these traits is succinct:

The Big Five factors and their constituent traits can be summarized as follows:

Openness - appreciation for art, emotion, adventure, unusual ideas, imagination, curiosity, and variety of experience.

Conscientiousness - a tendency to show self-discipline, act dutifully, and aim for achievement; planned rather than spontaneous behaviour.

Extraversion - energy, positive emotions, surgency, and the tendency to seek stimulation and the company of others.

Agreeableness - a tendency to be compassionate and cooperative rather than suspicious and antagonistic towards others.

Neuroticism - a tendency to experience unpleasant emotions easily, such as anger, anxiety, depression, or vulnerability; sometimes called emotional instability.

Florida’s findings?

Interestingly, America’s psychogeography lines up reasonably well with its economic geography. Greater Chicago is a center for extroverts and also a leading center for sales professionals. The Midwest, long a center for the manufacturing industry, has a prevalence of conscientious types who work well in a structured, rule-driven environment. The South, and particularly the I-75 corridor, where so much Japanese and German car manufacturing is located, is dominated by agreeable and conscientious types who are both dutiful and work well in teams.

Is this a self-fulfilling prophecy? Do people move to a specific area because it’s full of people like themselves, or are these areas simply full of these kinds of people due to age-old immigration patterns? The research can’t really say, but Florida does make some educated guesses.

The Northeast corridor, including Greater Boston, as well as San Francisco, Los Angeles, Seattle, and Austin, are home to concentrations of open-to-experience types who are drawn to creative endeavor, innovation, and entrepreneurial start-up companies. While it is hard to identify which came first — was it an initial concentration of personality types that drew industry, or the industry which attracted the personalities? — the overlay is clear.

One of the things interesting to me, and not mentioned in the article, is that the entire West coast is completely absent from representation on the maps. This must be due to lack of data or something, because it’s hard to imagine that California doesn’t have a specific concentration of a certain type of person.

You can view all five maps of the USA’s psychogeography here (PDF).

Yes, I’m starting a new tradition. Please join in if you’d like.

But for most Americans, Mental Health Month is meant to highlight mental health issues in a positive light to help people better understand them. Understanding something means not being so afraid of it, and if you’re not so afraid of something, maybe you won’t seek to avoid that thing in your life (e.g., stigmatize it). Virtually every big health condition or concern has such an “awareness month.”

Mental Health America, formerly the National Association for Mental Health, brings us a timely survey this month to let us know something that I think most people already knew — most people have friends. They also found these surprising results:

• Most people have an emotional bond with at least one other person
• Most people talk to other people about important decisions in their lives
• Most people have someone in their lives that appreciates them for who they are

Heady stuff, no?

The survey is meant to support MHA’s theme for Mental Health Month this year — “Get Connected.” But with response rates well over 90%, it shows that most people already have strong social connections in their lives. And while we may believe a larger social network benefits all, the research is decidedly mixed on whether social relationships help buffer stress. But don’t let the data mess up a good PR opportunity:

Research shows that social connectedness can reduce stress and promote overall health by providing a sense of belonging, self-worth and security.

“Individuals who feel valued and cared for are better equipped to deal with stress and adversity and even experience less severe illnesses than those with little social support,” said David Shern, Ph.D., president & CEO of Mental Health America. “The results of this survey are overwhelmingly positive because they show that most Americans do, in fact, have supportive relationships and that they recognize the vital role these relationships play in protecting them from depression and other illnesses.”

This sounds like the stress-buffering model (as described in Burton et. al., 2004):

This interactive model posits that, when faced with troubling life events, individuals with greater support from family and friends are less likely to become depressed than individuals with lower levels of support. This social support presumably enhances efficacy, esteem, and confidence, thereby increasing an individual’s perception that he or she can cope effectively with negative life events. In addition, the tangible support provided by network members may directly facilitate the resolution of negative life events (e.g., financial assistance).

But unfortunately, despite the fact that this theory is widely accepted, there’s actual little positive research support for it. I’ll let Burton et. al. (2004) tell you:

In sum, results from our study provided support for the assertions that negative life events and deficits in social support increase the risk for development of depressive pathology, but they also suggest that only certain sources of support had predictive power.

More importantly, despite the fact that the stress-buffering hypothesis is widely accepted (e.g., S. Cohen & Wills, 1985; Leavy, 1983), our review of the literature suggested that there was very little prospective support for this interactive model. Although we attempted to provide a more sensitive test of this model by improving on certain limitations of past studies, we still did not find support for the stress-buffering model.

This state of affairs suggests that it might be prudent to acknowledge that this intuitively attractive model does not accord with [our] findings and implies that we should refocus our research efforts on new etiologic accounts concerning how risk factors may work together to promote depressive pathology.

Of course social relationships in our lives are important. Lack of social support can be (but isn’t always) predictive of future depressive symptoms. But the mere presence of social relationships isn’t going to help “protect” you from future stress or depressive symptoms.

Mental Health America’s survey reveals that most people share this false belief about the stress-buffering effect. Nearly all respondents believe that having close relationships helps people relieve stress (94%) and helps protect them from developing depression and other mental health conditions (93%). Slightly less (86%) believe that not having close relationships can put them at risk for illness.

So, Happy Mental Health Month! Let’s get it off to a start on the right foot by being honest about how far “social connectedness” can really take a person. Having positive social relationships in your life is important, but probably not in the way suggested by Mental Health America’s press release.

Reference:

Burton, E., Stice, E. & Seeley, J.R. (2004). A Prospective Test of the Stress-Buffering Model of Depression in Adolescent Girls: No Support Once Again. Journal of Consulting and Clinical Psychology, 72(4), 689-697.

The studies were published in the latest issue of the American Journal of Psychiatry and both studies largely showed no positive association between the use of stimulant medication in children and an increased risk of substance abuse later on in life. The first study, Biederman et. al. (2008) reported on the 10-year followup of 112 children who were between 6 and 17 years-old when first entered into the study:

In a longitudinal sample of male subjects diagnosed with ADHD in childhood and followed up for 10 years into their young adult years, we found no evidence that prior treatment with stimulants was associated with subsequent increased or decreased risk for alcohol, drug, or nicotine use disorders. Further, we did not detect any significant association between age at stimulant treatment onset and subsequent substance use disorders or any associations between the duration of stimulant treatment and subsequent substance use disorders. These findings support the hypothesis that stimulant treatment does not increase the risk for subsequent substance use disorders.

The second study, Mannuzza et. al. (2008) showed more mixed results. While they did find an association between stimulant use for the treatment of ADHD and later substance use disorders, it was accounted for by a third, unexpected factor — antisocial personality disorder. Subjects who didn’t start stimulant medication until they were between ages 8 and 12 had greater substance abuse that was mediated by an increase in antisocial personality disorder in adulthood. Subjects with early stimulant treatment — before the age of 8 — did not differ from comparison subjects in lifetime rates of non-alcohol substance use.

So kids who are diagnosed and begin medication treatment later in childhood may be at more risk for later substance abuse because of the development of an antisocial personality disorder. There really is no adequate explanation for the greater prevalence of antisocial personality disorder in the later treatment group compared to the earlier treatment group, which the journal’s accompanying editorial notes:

The authors discuss the possibility that early stimulant treatment of ADHD may have a protective effect toward the emergence of conduct disorder, which usually precedes antisocial personality disorder and increases the risk for drug abuse. However, this hypothesis is not supported by early findings from the Multimodal Treatment Study of ADHD, in which treatment with stimulants in this prospective follow-up study did not selectively reduce conduct disorder, or by national trends over the past decade, when there has been a dramatic fivefold increase in the treatment of ADHD children in the United States with stimulants but no change in the prevalence of conduct disorder.

The upshot is that these studies confirm a large body of evidence that suggests there is little direct connection between the prescription of stimulant medications to children for ADHD and later substance abuse issues. The second study did find a link, but it seems to be because of the development of antisocial personality disorder. Further research is needed to determine the link between stimulant medications and this disorder.

The accompanying editorial puts the results into further perspective.

References:

Biederman J, Monuteaux MC, Spencer T, Wilens TE, MacPherson HA, Faraone SV (2008). Stimulant therapy and risk for subsequent substance use disorders in male adults with ADHD: a naturalistic controlled 10-year follow-up study. Am J Psychiatry, 165, 597–603.

Mannuzza S, Klein RG, Truong NL, Moulton JL III, Roizen ER, Howell KH, Castellanos FX. (2008). Age of methylphenidate treatment initiation in children with ADHD and later substance abuse: prospective follow-up into adulthood. Am J Psychiatry, 165, 604–609.

A publication that is largely information that’s been regurgitated time and time again (you can see many of the same topics in NIMH’s Women and Depression brochure), culled from a myriad of sources (sadly, not a single one of them attributed in the brochure, meant for consumers), reproducing little tidbits of facts long known, such as:

• An estimated one in eight women will experience depression in their lifetimes; twice the rate as men, regardless of race or ethnic background
• Middle-aged Hispanic women have the highest rate of depressive symptoms, followed by middle-aged African American women.
• Young Asian American women have the highest rate of younger groups and the 2nd highest rate of suicide among 15 to 24 year olds.
• American Indians and Alaska Native adolescents are the most likely to attempt suicide and die from it.

Interesting, if any of this were new data, but none of it is.

What the brochure really needed was a decent editor, because it’s full of nonsensical statements. Excuse me for shooting a few fish in a barrel, but we expect a higher standard from an organization like NAMI.

I picked a few of our favorites from the brochure, although there are many more to choose from. Let’s start with one of my favorites, What causes depression?

Researchers suspect that, rather than a single cause, many factors unique to women’s lives play a role in developing depression.

The section on “Causes” then goes on to talk about genetics, biology, psychosocial, victimization and poverty. Few of these factors are unique to women. Obviously women have similar genetic makeup as men and no research has implicated a female-specific gene as being the cause of depression in women. Same with the psychosocial — men have pessimistic thinking, low self-esteem and can worry a lot too. There’s been no research to show these kinds of factors are more significantly prevalent in women (except, perhaps, low self-esteem).

Victimization and poverty are really sub-topics under psychosocial, since they indeed deal with social aspects of living within a shared society. While poverty bias is prevalent in non-industrialized countries, it is on more equal footing in the U.S. and other industrialized countries. It’s likely that depression doesn’t discriminate when it comes to the incidence of depression amongst poor men and women.

Men have biology, too, of course, but women’s biology can indeed be more of a contributing factor to depression. Postpartum depression, for instance, is a very real and serious concern for many women after childbirth. Oddly, however, it is mentioned briefly only once in the entire brochure. This would’ve been an ideal opportunity to dispel many of the common misconceptions about this type of depression unique to women, but the brochure largely fails to do so.

Let’s see if the brochure presents a balanced picture about antidepressant medications (FYI, Wyeth is the maker of Effexor).

Selective serotonin reuptake inhibitors (SSRIs) are the most widely used antidepressants. They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and fluvoxamine (Luvox).

Serotonin and norepinephrine reuptake inhibitors (SNRIs) are the second most popular antidepressants worldwide. They include venlafaxine (Effexor) and duloxetine (Cymbalta).

Bupropion (Wellbutrin) is a very popular antidepressant classified as a norepinephrine-dopamine reuptake inhibitor (NDRI).

[…]

Older agents, such as the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), are used rarely now as first-line treatment. Although TCAs are similar to SNRIs, they have higher rates of side effects. Their use is generally limited to cases where other antidepressants have failed. TCAs include amitriptyline (Elavil, Limbitrol) desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil) nortriptyline (Pamelor, Aventyl), and protriptyline (Vivactil).

Naturally I expected to find the myth that tricyclic antidepressants (TCAs) have more side effects than their modern counterparts, SSRIs and SNRIs. Notice, too, the very subtle bias introduced in the sentence — it mentioned only SNRIs, not SSRIs. Wyeth just so happens to make a SNRI, not an SSRI.

A more balanced review of the research literature shows that SSRIs, SNRIs, and tricyclic antidepressants all have side effects. The only question is what kind of side effects are more tolerable to you — not being able to perform sexually, or having a dry mouth? Of course, this is a simplistic reductionist argument I’m making on purpose (actual side effects vary widely), but it shows that data can be spun whatever way is most advantageous to the spinner.

In this case, the author (who is unnamed in the brochure) clumped tricyclic antidepressants with an entirely different class of antidepressants that is indeed rarely prescribed any longer. (They took pains to separate out different classes in the preceding paragraphs.) Then it repeated myths about TCAs which are popular, but largely untrue if taken out of context.

And last, but not least, let’s make sure people are confused about whether psychotherapy will be covered by one’s health insurance:

Private therapists usually accept only private insurance and some therapists don’t accept any health insurance.

Huh? Which is it? Do they accept only private insurance, or no insurance at all? The two seem directly contradictory, especially when they appear in the same sentence.

The truth is that most therapists accept a wide range of health insurance plans. A certain number of mental health outpatient visits are usually available at low-cost via your employer’s health insurance plan, requiring a small co-pay (usually between $20 - $50). Some plans limit the number of sessions to 12 before requiring additional authorization from the insurance plan.

By the wording of this sentence, the brochure seems to imply that seeing a private therapist is difficult to get payment for psychotherapy treatment. While indeed there may be some people who have such difficulty, some people also have difficulty getting a brand-name drug paid for by their health plan (especially if only generics are covered, as is increasingly becoming commonplace).

Read our news story about this brochure: Insights on
Download the NAMI brochure: Women and Depression (PDF)

Deep brain stimulation is not a new procedure, but its use in the treatment of depression (as well as severe OCD) is. It’s been used successfully for about 20 years in the treatment of Parkinson’s disease.

New research was presented on Tuesday at the American Association of Neurological Surgeons annual meeting in Chicago. In the study, 15 people received the DBS electrode implants. These people had been suffering from severe depression for at least five years and had tried other forms of treatment with no success.

Six months later, 7 of the 15 subjects had at least a 50 percent reduction in their depressive symptoms, based on a commonly used depression scale. But even subjects who didn’t enjoy a 50 percent reduction in their symptoms still experienced some symptom reduction. All subjects said they would undergo the DBS procedure again (even if it didn’t significantly help them).

Keep in mind, people with severe depression and who’ve tried other forms of treatment with no success are often at the end of their ropes in terms of hope and finding a treatment that works for them. These are often the “worst of the worst,” and turn to these types of procedures in hope of finding relief from their depression. Even if only half of the patients studied enjoyed significant relief from the treatment, DBS appears to be a better treatment option than many others with far more severe side effects (ECT comes to mind, with its unpredictable memory loss).

I’m all for new treatments of severe depression, especially those that appear to be well-tolerated with few negative side effects. I hope future research into DBS for depression bears out these preliminary kinds of findings.

Read the full article: Brain Stimulation for Treatment Resistant Depression

This Summit is designed so that participants will be able to:

• describe how to use telemedicine and other emerging information technologies to support the integration of
  behavioral health into primary care and chronic disease management
• learn how to e-empower health consumers through the design, use, and evaluation of technology-assisted
  self-care
• identify and describe barriers to the spread of telehealth and telemedicine as well as strategies to overcome
  these barriers
• describe the impact of depression on productivity in the workplace and discuss approaches to address this
  problem

I will also be hosting a panel discussion during the conference, details below:

SESSION 4.3: PANEL DISCUSSION: SOCIAL NETWORKING AND HEALTH

With the popularity of social networking sites like MySpace and Facebook, companies have turned their eyes toward healthcare and patients. How can patients fully participate on these sites and still protect their privacy? Who owns their shared data and experiences, and can they ever be removed? How do such sites enable patients to find others like themselves, to share experiences and knowledge about their disorders? And how can such social networking sites point us to the future by becoming early warning systems for adverse drug events or identifying the downsides to the newest fad or experimental treatments? This panel will examine these questions and demonstrate some of the emerging social networking sites for health and behavioral health concerns.

Moderator:
John M. Grohol, PsyD, CEO & Publisher, PsychCentral.com

Panelists:
Enoch Choi, MD, Product Manager, MedHelp.org & Family Medicine Physician, Urgent Care Department, Palo Alto Foundation Medical Group
Nathan Cobb, MD, Research Fellow, Tobacco Treatment and Research Center, Massachusetts General Hospital & Harvard Medical School
Jeana Frost, PhD, Research Scientist, PatientsLikeMe
Benjamin C. Williams, CEO, Firefly Health (CarePlace)

I think it’s going to be a great panel discussion and am looking forward to it!

If you plan on attending the summit and would like to meet for lunch one day, I’ll be happy to do so… Leave a note in the comments, or email me.

Since those procedures have long since stopped, the profession of psychiatry has come under criticism for other things, such as forced treatment, its cozy relationship with pharmaceutical companies, and its continuing endorsement of radical procedures such as electroconvulsive therapy (ECT). When people feel strongly about something, they often see things in extremes rather than shades of gray.

We live in a complex and sometimes confusing world, however, and the extremes are rarely informative. Black and white make for good silhouettes, but they don’t make for such a good painting or photograph. And for most of us, life is more like a rich painting rather than a bleak, black and white silhouette.

Philip is one of those individuals, from reading his entries, that seems to understand the richness of life and complexity of the issues most of us face in our daily lives. Yes, there are evils propagated by virtually all professions. But those evils are the exception, not the rule. Medications don’t work for everyone, but neither does psychotherapy. We shouldn’t paint everyone into a corner (or a single type of treatment) based upon our own negative experiences with treatment.

So whether he meant to or not, he started an interesting conversation yesterday with this entry, directed toward the people who regularly comment in his blog, Notes For Anti-Psychiatrists…And Psychiatrists, Too! The 40+ comments are worth the read too.

CL Psych provides us with a further analysis of Paxil study 329, one where apparently the researchers went to great lengths to find efficacy. Why the re-examination of this study?

Because another study was just published in the International Jouranl of Risk and Safety in Medicine. The new study examined the internal documents, full dataset and drafts that were released related to a lawsuit against the makers of Paxil. The damning findings from the new study?

5.1. Were the results for study 329 positive or negative?

There was no significant efficacy difference between paroxetine and placebo on the two primary outcomes or six secondary outcomes in the original protocol. At least 19 additional outcomes were tested. Study 329 was positive on 4 of 27 known outcomes (15%). There was a significantly higher rate of SAEs with paroxetine than with placebo. Consequently, study 329 was negative for efficacy and positive for harm.

5.2. Did selective reporting occur?

Claims that paroxetine was “generally well tolerated and effective” arose from selective reporting of the 15% of outcomes that were positive and selective under reporting of the other efficacy and SAE findings. The JAACAP paper has been defended on the grounds that readers could read in the results table that the two outcomes described as primary elsewhere (but not in that table) were negative.

However readers are more likely to be influenced by the abstract than the tables of a clinical trial report, as evidenced by the continued retransmitting of the false impression that study 329 found “significant efficacy on one of the two primary endpoints”. A likely cause of this misunderstanding is the conflation of ‘remission’ and ‘responder’ and especially the false statement that “paroxetine separated statistically from placebo at end point among 4 of the parameters: [including] response (i.e. primary outcome measure) . . .”.

In other words, the researchers carefully picked over the data to present only the data in the published study that were most favorable to the drug that paid for the study — Paxil. This pretty much shows the major, gaping hole in the peer-review process — that journals can only ask questions about what they’re told about. If researchers conceal the true design of a study (or negative data), then journals will get a biased picture. And then happily publish such a picture completely oblivious to the truth.

Another surprising finding was that the study wasn’t written by the authors listed. It was ghostwritten by someone with a master’s degree. You need look no further than the first draft to see the proof of this. I don’t know whether this is standard operating procedure for studies of this size, but you’d expect such authorship would be noted as it is in traditional publishing.

You can read all about the picking apart of Study 329 over at Healthy Skepticism. The scary thing is that nobody knows how widespread these kinds of biases are in the published research. This is one study out of thousands of similar peer-reviewed, published studies. Could other published studies suffer from similar problems? And if so, to what degree is the published literature tainted by these kinds of underhanded methods?

We may never know.

It is not unusual to feel strong feelings of “love” or affinity toward your therapist. But those feelings probably aren’t what you think.

Psychodynamic theory suggests the reason that many people fall in love with their therapist is because they are repeating emotional patterns they experienced as children toward their parents. This behavior and set of feelings was first described by Sigmund Freud who coined the term “transference” to describe it. He discovered transference after noting this many of his mostly-female clients would start describing their own romantic feelings toward him. In some patients, the feelings were not romantic, but instead more childlike and Freud took on a parental role in the patient’s mind. It was as though Freud became their father figure, and the tempestuous relationship would then play out in his office.

Freud described this process over a hundred years ago, and therapists and their clients still deal with this issue even in modern psychotherapies like cognitive-behavioral therapy. Because the process itself is a very real possible side effect of psychotherapy, although it doesn’t happen to everyone in all therapeutic situations.

Why Does Transference Occur?

Nobody can say for certain why transference seems to be a process of many people’s psychotherapy, regardless of the actual background of the therapist or focus of therapy. Goal-focused, short-term psychotherapy is no guarantee that transference won’t occur. Some cognitive-behavioral therapists, in their efforts to focus on empirically-based treatments, simply ignore these feelings when they come up in the course of psychotherapy. Others downplay their importance.

Transference likely occurs because the therapeutic environment is generally seen as a safe, supportive and nurturing environment. Therapists are seen as accepting, positive influences in our lives, but sometimes also as authoritative guides. In these various roles, a therapist can inadvertently step into roles previously occupied in our lives by one of our parents. Or a client can become infatuated with the seemingly endless supply of wisdom and positive self-regard some therapists exude. The effects can be just as intoxicating as one’s first love. In this increasingly detached world, someone who spends nearly a full hour with our undivided attention may become quite godlike.

Therapists may also represent an individual in a person’s life that provided the unconditional acceptance (and perhaps love) that we all seek from important others in our life. Our mother. Our father. A sibling. A lover. A therapist doesn’t ask for a person to be anything other than themselves. And in the honest emotional environment that’s so often found in the best therapists’ office, it’s easy to idealize (and in some cases, idolize) the accepting, caring professional who sits across from us.

I Think I’m in Love! Now What?

So you feel like you’re in love with your therapist and while intellectually you may understand that this is just a normal process of psychotherapy for some, you still need to do something about it.

The first thing to understand is that this is not anything you should be ashamed or afraid of. This type of transference is not an uncommon feature of psychotherapy, and these kinds of feelings are not something you can simply just turn on and off at will. Having these feelings for your therapist is not “unprofessional” nor does it cross any kind of therapeutic boundaries.

Second, talk to your therapist. Okay, I know this is the hardest step, but it is also the most important. Your therapist should be experienced and trained in transference issues (yes, even the modern cognitive-behavioral therapists), and be able to talk to you about them in an open and accepting manner. As with most issues in therapy, bringing it out into the open and talking about it usually is sufficient to help most people in dealing with their feelings. Your therapist should also talk to you about ways you can better understand them in the context of your therapeutic relationship, family history and background, and what kinds of things you might be able to do to help and reduce their intensity.

Third, accept your feelings and continue in focusing on the reasons that brought you into therapy in the first place. For some people, this will be easy. Once they’ve discussed the issue with their therapist, they feel relieved – like a weight has been lifted off of their shoulders. For others, the process may be more difficult and require that some therapy time be spent further discussing these feelings with your therapist.

I should also note that if a therapist returns your feelings of love in any form whatsoever, it is a breach of the professional therapeutic relationship and ethics. Professional therapists are trained to cope with their own “counter-transference” issues, and in the U.S., a romantic relationship between a client and their therapist is considered unethical and verboten. You should consider ending your relationship with such a therapist and talking to your regional ethics board about filing a complaint.

“Falling in love” with your therapist is sometimes a normal process of psychotherapy. It only means that you’re feeling positive, intense feelings for another person who is helping you with important issues in your life. Do not run away from these feelings – or your therapist – in fear. Talk to your therapist about them, and chances are, it will help.

But what you may not know is the need for something else, which may be even more important — self-efficacy. That is, the belief that you have what you need in order to succeed (even if you don’t always do so).

People with self-efficacy often have very high standards for themselves, which brings about a paradox — they may not always have the highest self-esteem, nor do they always succeed (according to their own standards). What they do do is to never give up and always continue believing in themselves and their abilities.

The Wall Street Journal’s Melinda Beck has a column today about the role and importance self-efficacy has in our lives:

Still, such people succeed because they believe that persistent effort will let them succeed. In fact, if success comes too easily, some people never master the ability to learn from criticism. “People need to learn how to manage failure so it’s informational and not demoralizing,” says Prof. Albert Bandura.

Albert Bandura is the psychologist who first described this concept back in the 1970s and is still teaching it at Stanford University.

Self-efficacy differs from self-esteem in that it’s a judgment of specific capabilities rather than a general feeling of self-worth. “It’s easy to have high self-esteem — just aim low,” says Prof. Bandura

The column points out all of the setbacks some famous people have experienced, from Michael Jordan and Steve Jobs, to Harry Potter writer J.K. Rowling and Walt Disney. The key to each of these people’s success is that they never doubted their own abilities and believed in themselves and their contributions.

Self-efficacy has become a part of the positive psychology movement nowadays, and the concept of “resiliency.” The good news is that even if you don’t have a lot of self-efficacy or resiliency today, you can learn these skills and become more self-efficacious in your own life.

Where does such determination come from? In some cases it’s inborn optimism — akin to the kind of resilience that enables some children to emerge unscathed from extreme poverty, tragedy or abuse. Self-efficacy can also be acquired by mastering a task; by modeling the behavior of others who have succeeded; and from what Prof. Bandura calls “verbal persuasion” — getting effective encouragement that is tied to achievement, rather than empty praise.

It’s a good article describing a life skill and personality trait we may have admired in others, but didn’t quite know what it was or how to get some of it in our own lives.