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From the Menninger Clinic… about mentalizing.:
Mentalizing conference call with Drs. Peter Fonagy & Efrain Bleiberg
At the request of participants and the positive response to this November 2009 presentation on the interactive conference call, we are making this tape availalble.
Download conference call
Article from Science Daily about over-diagnosis of bipolar disorder:
If Bipolar Disorder Is Over-diagnosed, What Are The Actual Diagnoses?
ScienceDaily (July 29, 2009) — A year ago, a study by Rhode Island Hospital and Brown University researchers reported that fewer than half the patients previously diagnosed with bipolar disorder received an actual diagnosis of bipolar disorder after using a comprehensive, psychiatric diagnostic interview tool –the Structured Clinical Interview for DSM-IV (SCID). In this follow-up study, the researchers have determined the actual diagnoses of those patients.
Their study is published in the July 28 ahead of print online edition of The Journal of Clinical Psychiatry.
Under the direction of lead author Mark Zimmerman, MD, director of outpatient psychiatry at Rhode Island Hospital, the researchers’ findings indicate that patients who received a previous diagnosis of bipolar disorder that was not confirmed by a SCID, they were significantly more likely to be diagnosed with borderline personality disorder as well as impulse control disorders.
Their research involved the study of 82 psychiatric outpatients who reported that they received a previous diagnosis of bipolar disorder that was not later confirmed through the use of the SCID. The diagnoses in these patients were compared to 528 patients who were not previously diagnosed with bipolar disorder. The study was conducted between May 2001 and March 2005.
Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, says, “In our study, one quarter of the patients over-diagnosed with bipolar disorder met DSM-IV criteria for borderline personality disorder. Looking at these results another way, nearly 40 percent (20 of 52) of patients diagnosed with DSM-IV borderline personality disorder had been over-diagnosed with bipolar disorder.”
The results of the study also indicate that patients who had been over-diagnosed with bipolar disorder were more frequently diagnosed with major depressive disorder, antisocial personality disorder, posttraumatic stress disorder and eating and impulse disorders.
Zimmerman and colleagues note that “we hypothesize that in patients with mood instability, physicians are inclined to diagnose a potentially medication-responsive disorder such as bipolar disorder rather than a disorder such as borderline personality disorder that is less medication-responsive.”
In their previously published study that concluded bipolar disorder was over-diagnosed, they studied 700 patients. Of the 700 patients, 145 reported they had been previously diagnosed as having bipolar disorder; however, fewer than half of the 145 patients (43.4 percent) were diagnosed with bipolar disorder based on the SCID. The authors state that the over-diagnosis of bipolar disorder can have serious consequences, because while bipolar disorder is treated with mood stabilizers, no medications have been approved for the treatment of borderline personality disorder. As a result, over-diagnosing bipolar disorder can unnecessarily expose patients to serious medication side effects, including possible impact to renal, endocrine, hepatic, immunologic and metabolic functions.
Zimmerman concludes, “Because evidence continues to emerge establishing the efficacy of certain forms of psychotherapy for borderline personality disorder, over-diagnosing bipolar disorder in patients with borderline personality disorder can result in the failure to recommend the most appropriate forms of treatment.”
Along with Zimmerman, other researchers involved in the study include Camile Ruggero, PhD; Iwona Chelminski, PhD and Diane Young, PhD, all of Rhode Island Hospital and Brown University.
Last week, I was reading a portion of Dr. Marsha Linehan’s book “Cognitive Behavior Treatment Of Borderline Personality Disorder” and stumbled upon a reference that I had never noticed before. It reads:
Emotional validation strategies contrast with approaches that focus on the overreactivity of emotions or the distorted basis of their generation. Thus, they are more like the approach of Greenberg and Safran (1987), who make a distinction between primary or “authentic” emotions and secondary of “learned” emotions. The latter are reactions to primary cognitive appraisals and emotional responses; they are the end products of chains of feelings and thoughts. Dysfunctional and maladaptive emotions, according to Greenberg and Safran, are usually secondary emotions that block the experience and expression of primary emotions. These authors go on to suggest that “all primary affective emotions provides adaptive motivational information to the organism” (1987, p. 176). The important point here is the suggestion that dysfunctional and maladaptive responses to events are often connected or interwoven with “authentic” or valid responses to these events. Finding and amplifying these primary responses constitute the essence of emotional validation. The honesty of the therapist in applying these strategies cannot be overstressed. If emotional validation strategies are used as change strategies – that is, if lip service is given to validation in order to simply to calm the patient down for the “real work” – the therapist can expect the therapy to backfire. Such honesty, in turn, depends on the therapist’s belief that there is a substantial validity to be found, and that searching for it is therapeutically useful.
This idea is an important one for loved ones of those with BPD because it touches on several points:
- It acknowledges that emotional validation focuses on “normal” emotional reactions, not “the overreactivity of emotions or the distorted basis of their generation.” That is the way of emotional invalidation, i.e. “You’re overreacting to something trivial. Look at what really happened.” I see that expression from Non-BPs all the time.
- It points out the differences between primary and secondary emotions. This distinction is extreme useful for Non-BPs. Why? Because most often the anger and rage are secondary emotions (not always) and that is typically what Nons focus on. If the emotional validation is used for secondary emotions, then I interpret this as not therapeutic, because you are “validating the invalid.”
- Probing (gently and compassionately) for the primary emotions seems to be a more effective strategy and those are the emotions that can be validated effectively.
- One has to approach emotional validation as a tool unto itself – without using it as a “change strategy.” That is, “it is ok to feel that, but you have to change the way you feel to be ‘normal’.” That is, bound to backfire.
- If this distinction of primary and secondary emotions – the first being true and “authentic”, the second being dysfunctional and maladaptive – is applied to the concept of mentalization, then the idea within mentalization to use emotional validation to probe for further feelings begins to make more sense. One has to help the BP locate the primary emotion.
 When Hope is Not EnoughGet the Non-BP book that has helped hundreds!
One of the things I have noticed about Dialectical Behavior Therapy Family Skills versus Mentalization Based Skills is that they operate at a different link on the behavioral chain. In “When Hope is Not Enough” I have a section called “the BPD Dynamic.” What this dynamic outlines is a behavioral chain. That chain goes like this:
Event -> Interpretation -> Emotional/Physical Feelings -> Action Impulses -> Expression and Behavior
DBT-FST seems to me to operate at the Action Impulses to Expression and Behavior link, while validating the Emotional/Physical Feelings link. Don’t get me wrong, the DBT-FST skills are extremely powerful in communicating with someone with BPD. Yet, the change that is requested is at the end of the chain. I have heard that Marsha Linehan is quoted as saying something like, “Just because you feel like a crazy person, doesn’t mean you have to behave like one.” The point here is that DBT is a behavioral therapy and by modifying behavior, that works backwards toward regulating emotion and tolerating distress. In other words, DBT trains you to behave differently based on your feelings. When you gradually learn that your new behavior is more effective than the previous behavior, you break the conditioned chain between Action Impulses and Expression and Behavior. That is the essence of the DBT skill “Opposite Action.” An interesting side note is that by practicing Opposite Action (that is, doing the exact opposite of what your feelings implore you to do – such as engaging when you feel sad, rather than hiding under the covers all day), you actually feel better, because the action does work backward. Dr. Paul Ekman found that configuring one’s face to mimic a certain feeling actually causes that feeling to be experienced. That is the theory behind DBT’s “Half Smile” skill. Ultimately though, by working at that link in the chain, the person still feels the emotion, yet he or she just behaves differently than the emotion originally informed him/her to behave.
MBT on the other hand takes on the on the problem at the Interpretation link. By asking questions and being open to alternative interpretations, the person with BPD is more likely to have a broader view of other people’s behavior and the events in life. DBT never asks about the intent or motivation of the other person and just takes the interpretation as a given in a person with BPD. If a person with BPD says something happens and that something means X, then in DBT it means X. There is very little questioning of the validity of the interpretation X. In MBT, however, the interpretation X can be questioned and alternative interpretations (such as Y or Z) can be examined. The nice thing about this is that when the person with BPD is faced with a similar situation, he/she is less likely to jump to conclusion X and might consider Y or Z.
An example of the differences in the two approaches is as follows:
My daughter comes home from school after being teased by a boy on the playground. My daughter ends up throwing a thermos at the boy’s head.
With DBT, I would validate her anger and ask her how she could behave more effectively the next time this teasing occurs. So next time she will behave more effectively and not throw the thermos.
With MBT, I would validate her feelings and begin to probe with curious and straight-forward questions as to the intent of the boy. Perhaps he actually likes my daughter and that is why he is teasing. Perhaps he is showing off to his friends. If this approach is taken, my daughter is more likely to consider the boy’s motivation for the teasing. If she understands the motivation, she can actually never get angry and risk throwing the thermos.
All of that being said, I believe these skills have to be learned as a “ladder” to effectiveness. You can’t start at point E without going through points A-D. DBT-FST provide the foundation for more advanced skills, like those in MBT.
I reopened the diagnosis poll now that I am getting more traffic. I have noticed in my email list and in general that BP’s go through at least 8 therapists before they start being real with someone. My wife has been through at least 10 therapists before she admitted to the suicidal ideation and the self-injury. She immediately dropped a therapist who diagnosed her with BPD. Is that you guy’s experience as well?
OK readers, now is the time to revisit Lindsay (I think I was spelling her first name wrong for a while there) Lohan and possible BPD. She has all of the classic signs of the disorder. I was struck by this quote:
“Sam and Lindsay are speaking,” the source tells PEOPLE. “But Sam has begged Lindsay to get help.”
“Lindsay, despite appearances, is insecure and has relied on Samantha and their relationship to build her up,” explains the pal. “Lindsay barely sleeps, which explains a lot of her behavior. She’s exhausted. She can’t even sit down for a minute without pacing around the room. It’s really sad.”
Sam is begging Lindsay to get help? For what? Well, perhaps we know. Looking at Lindsay’s case, I can’t help but see Borderline Personality Disorder (BPD). She is erractic, emotional and sexually confused. She has all the classic signs of an untreated person with BPD. I hope she gets help – and I hope that, if she is diagnosed with BPD, she would come out publically and say so – to reduce the stigma of the disorder.
 Lindsay Lohan and BPD?
 Here is a new article from Time magazine on Borderline Personality Disorder (BPD):
Thursday, Jan. 08, 2009
Minds on The Edge
By John Cloud/Seattle
Doctors used to have poetic names for diseases. A physician would speak of consumption because the illness seemed to eat you from within. Now we just use the name of the bacterium that causes the illness: tuberculosis. Psychology, though, remains a profession practiced partly as science and partly as linguistic art.
Because our knowledge of the mind’s afflictions remains so limited, psychologists–even when writing in academic publications–still deploy metaphors to understand difficult disorders. And possibly the most difficult of all to fathom–and thus one of the most creatively named–is the mysterious-sounding borderline personality disorder (BPD). University of Washington psychologist Marsha Linehan, one of the world’s leading experts on BPD, describes it this way: “Borderline individuals are the psychological equivalent of third-degree-burn patients. They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering.”
Borderlines are the patients psychologists fear most. As many as 75% hurt themselves, and approximately 10% commit suicide–an extraordinarily high suicide rate (by comparison, the suicide rate for mood disorders is about 6%). Borderline patients seem to have no internal governor; they are capable of deep love and profound rage almost simultaneously. They are powerfully connected to the people close to them and terrified by the possibility of losing them–yet attack those people so unexpectedly that they often ensure the very abandonment they fear. When they want to hold, they claw instead. Many therapists have no clue how to treat borderlines. And yet diagnosis of the condition appears to be on the rise.
A 2008 study of nearly 35,000 adults in the Journal of Clinical Psychiatry found that 5.9%–which would translate into 18 million Americans–had been given a BPD diagnosis. As recently as 2000, the American Psychiatric Association believed that only 2% had BPD. (In contrast, clinicians diagnose bipolar disorder and schizophrenia in about 1% of the population.) BPD has long been regarded as an illness disproportionately affecting women, but the latest research shows no difference in prevalence rates for men and women. Regardless of gender, people in their 20s are at higher risk for BPD than those older or younger.
What defines borderline personality disorder–and makes it so explosive–is the sufferers’ inability to calibrate their feelings and behavior. When faced with an event that makes them depressed or angry, they often become inconsolable or enraged. Such problems may be exacerbated by impulsive behaviors: overeating or substance abuse; suicide attempts; intentional self-injury. (The methods of self-harm that borderlines choose can be gruesomely creative. One psychologist told me of a woman who used fingernail clippers to pull off slivers of her skin.”
No one knows exactly what causes BPD, but the familiar nature-nurture combination of genetic and environmental misfortune is the likely culprit. Linehan has found that some borderline individuals come from homes where they were abused, some from stifling families in which children were told to go to their room if they had to cry, and some from normal families that buckled under the stress of an economic or health-care crisis and failed to provide kids with adequate validation and emotional coaching. “The child does not learn how to understand, label, regulate or tolerate emotional responses, and instead learns to oscillate between emotional inhibition and extreme emotional lability,” Linehan and her colleagues write in a paper to be published in a leading journal, Psychological Bulletin.
Those with borderline disorder usually appear as criminals in the media. In the past decade, hundreds of stories in major newspapers have recounted violent crimes committed by those said to have the disorder. A typical example from last year was the lurid tale of an Ontario man labeled borderline who used a screwdriver to gouge out his wife’s right eye. (She lived; he got 14 years.”
There are several theories about why the number of borderline diagnoses may be rising. A parsimonious explanation is that because of advances in treating common mood problems like short-term depression, more health-care resources are available to identify difficult disorders like BPD. Another explanation is hopeful: BPD treatment has improved dramatically in the past few years. Until recently, a diagnosis of borderline personality disorder was seen as a “death sentence,” as Dr. Kenneth Silk of the University of Michigan wrote in the April 2008 issue of the American Journal of Psychiatry. Clinicians often avoided naming the illness and instead told patients they had a less stigmatizing disorder.
Therapeutic advances have changed the landscape. Since 1991, as Dr. Joel Paris points out in his 2008 book, Treatment of Borderline Personality Disorder, researchers have conducted at least 17 randomized trials of various psychotherapies for borderline illness, and most have shown encouraging results. According to a big Harvard project called the McLean Study of Adult Development, 88% of those who received a diagnosis of BPD no longer meet the criteria for the disorder a decade after starting treatment. Most show some improvement within a year. Continue reading Interesting Article from Time Magazine on BPD
I am posting this story because in this case the victim of the issue is the person with BPD. Her care giver is charged with neglect of the patient:
Article published Dec 5, 2008
Innocent plea entered by caregiver in case where woman died
By Thatcher Moats Times Argus Staff
BARRE – Julie Davis is accused of doing too little too late to help a vulnerable adult who died while in her care last summer.
Davis, 47, of Calais pleaded innocent in Vermont District Court in Barre Thursday to neglect of a vulnerable adult by a caregiver, which carries a potential penalty of 15 years in prison and a $10,000 fine.
Davis was the caregiver responsible for Jean Lemire when Lemire, 45, died last August of hypothermia after being removed from Davis’ Calais home.
Lemire’s core body temperature was 82 degrees when she arrived at Central Vermont Medical Center, and she had multiple bruises, lacerations and a broken rib, court records state. When rescue workers found Lemire, she was soaking wet and had significant bruising on her face and chest, according to Jay Copping of the East Calais rescue squad. Lemire had been eating mud and grass, and Copping told police that he extracted muddy water and grass from Lemire as he attempted to force a tube down her throat.
The court records paint a picture of Lemire as a difficult person to handle, who become more so in the days leading up to her death. Her worsened condition may have been triggered by news of the death of her nephew, who family members said she was close to. Lemire was also scheduled to be moved from Davis’ residence, according to the affidavit, which also may have caused anxiety.
Davis told investigators that Lemire was a self-mutilator who would punch herself in the face and slam her face into the walls. Davis said that in the five days before she died, Lemire refused to sleep and often ran into the woods naked. She also ran over to a neighbors’ house without her clothes on a few days before her death.
On the day of Lemire’s death, Davis said Lemire had been given her morning dose of medication and then spent the majority of the day outside.
However, Davis didn’t call 911 until Lemire collapsed and stopped breathing. Davis had been trying to get Lemire to eat and drink Gatorade, she told investigators, and she performed CPR on Lemire until rescue workers arrived.
Shirley Cichonowicz, a sister and guardian of Lemire, told police that at the hospital the family decided to take Lemire off life support. Lemire died that Aug. 9 at about 10 p.m., according to court records.
Thursday’s proceeding in Vermont District Court in Barre was brief, and Davis was released on conditions. About 15 of Lemire’s family members were in the courthouse, and they filed out of the courtroom after the arraignment but declined to comment.
In an interview with police, Davis’ supervisor and Lemire’s case manager, Karen Daley-Regan, said that Lemire should have been placed in a crisis home based on her behavior in the days before her death.
Daley-Regan said that Lemire’s behavior before her death was uncharacteristic. But she also said that Lemire was known to take her clothes off and had an eating disorder, two of the things that lead to the woman’s death.
On Aug. 5, Daley-Regan prepared a monthly log that indicated no irregular issues with Lemire or Davis, court records state.
But the next day Davis reported that Lemire had gone to a neighbor’s home naked.
Daley-Regan then told Davis that she needed to have her eyes on Lemire at all times, but Daley-Regan did not do a home visit.
Daley-Regan told police that on Aug. 7 she checked in with Davis, who did not say there was an emergency.
Daley-Regan told police that had she known what was going on at the Davis residence, she would have intervened.
Davis told investigators that she tried to communicate what was going on when she talked to Daley-Regan, but also admitted she did not try hard enough. Davis also told police that she knows she should have done more to help Lemire, according to court records.
Communication was not Davis’ strength, according to a former colleague who was the case manager for one of Davis’ previous clients.
Troy Busconi, of the Vermont Crisis Intervention Network at Upper Valley Services, was the case manager for Shawn Leary, whom Davis cared for at one time.
Busconi told police that Davis lacked communication skills, and said he heard about a seizure that Leary had had only long after the incident. And when Davis asked for help, she would “not communicate it directly,” Busconi told investigators.
Davis had a limited skill set, but did the best she could, Busconi told police.
Last May, Adult Protective Services received a complaint that a caregiver was being abusive to her client in a local drugstore. The complainant, Lisa Sargent, took down the license plate number on the vehicle, which was registered to Doug Ballou, who lived with Davis in Calais.
Sargent also told police that the caregiver was referring to the client as “Jean.”
Another caregiver told police that he witnessed Davis scream at Lemire to get her to do things.
It also appears that Lemire was not the first client to die while in the care of Davis. The affidavit is not entirely clear on how much responsibility Davis may have had for the death of a man named Doug Lafrance, who, according to court records, died of pneumonia. But he was in her care when he died, according to the affidavit.
Police pointed out that in the two deaths, Davis did not call 911 until it was too late.
Lemire had been a client of Lincoln Street Inc., a non-profit agency based in Springfield, dedicated to caring for people with developmental disabilities, for 24 years. She was diagnosed with borderline personality disorder, according to the affidavit, and also suffered from anorexia, bulimia, seizure disorder and other conditions.
Lemire required daily doses of a handful of mood stabilizing and anti-depressant drugs.
Davis, who has been a homecare provider for 11 years, began caring for Lemire late last March.
Joan Senecal, the commissioner of the state Department of Aging and Disability, could not be reached for comment yesterday. Cheryl Thrall, the executive director at Lincoln Street declined to comment.
A report from the AP on study:
1 in 5 Young Adults Has Personality Disorder, Study Finds
Tuesday , December 02, 2008
AP
CHICAGO —
Almost one in five young American adults has a personality disorder that interferes with everyday life, and even more abuse alcohol or drugs, researchers reported Monday in the most extensive study of its kind.
The disorders include problems such as obsessive or compulsive tendencies and anti-social behavior that can sometimes lead to violence. The study also found that fewer than 25 percent of college-aged Americans with mental problems get treatment.
One expert said personality disorders may be overdiagnosed. But others said the results were not surprising since previous, less rigorous evidence has suggested mental problems are common on college campuses and elsewhere.
Experts praised the study’s scope — face-to-face interviews about numerous disorders with more than 5,000 young people ages 19 to 25 — and said it spotlights a problem college administrators need to address.
Study co-author Dr. Mark Olfson of Columbia University and New York State Psychiatric Institute called the widespread lack of treatment particularly worrisome. He said it should alert not only “students and parents, but also deans and people who run college mental health services about the need to extend access to treatment.”
Counting substance abuse, the study found that nearly half of young people surveyed have some sort of psychiatric condition, including students and non-students.
Personality disorders were the second most common problem behind drug or alcohol abuse as a single category. The disorders include obsessive, anti-social and paranoid behaviors that are not mere quirks but actually interfere with ordinary functioning.
The study authors noted that recent tragedies such as fatal shootings at Northern Illinois University and Virginia Tech have raised awareness about the prevalence of mental illness on college campuses.
They also suggest that this age group might be particularly vulnerable.
“For many, young adulthood is characterized by the pursuit of greater educational opportunities and employment prospects, development of personal relationships, and for some, parenthood,” the authors said. These circumstances, they said, can result in stress that triggers the start or recurrence of psychiatric problems.
The study was released Monday in Archives of General Psychiatry. It was based on interviews with 5,092 young adults in 2001 and 2002.
Olfson said it took time to analzye the data, including weighting the results to extrapolate national numbers. But the authors said the results would probably hold true today.
The study was funded with grants from the National Institutes of Health, the American Foundation for Suicide Prevention and the New York Psychiatric Institute.
Dr. Sharon Hirsch, a University of Chicago psychiatrist not involved in the study, praised it for raising awareness about the problem and the high numbers of affected people who don’t get help.
Imagine if more than 75 percent of diabetic college students didn’t get treatment, Hirsch said. “Just think about what would be happening on our college campuses.”
The results highlight the need for mental health services to be housed with other medical services on college campuses, to erase the stigma and make it more likely that people will seek help, she said.
In the study, trained interviewers, but not psychiatrists, questioned participants about symptoms. They used an assessment tool similar to criteria doctors use to diagnose mental illness.
Dr. Jerald Kay, a psychiatry professor at Wright State University and chairman of the American Psychiatric Association’s college mental health committee, said the assessment tool is considered valid and more rigorous than self-reports of mental illness. He was not involved in the study.
Personality disorders showed up in similar numbers among both students and non-students, including the most common one, obsessive compulsive personality disorder. About 8 percent of young adults in both groups had this illness, which can include an extreme preoccupation with details, rules, orderliness and perfectionism.
Kay said the prevalence of personality disorders was higher than he would expect and questioned whether the condition might be overdiagnosed.
All good students have a touch of “obsessional” personality that helps them work hard to achieve. But that’s different from an obsessional disorder that makes people inflexible and controlling and interferes with their lives, he explained.
Obsessive compulsive personality disorder differs from the better known OCD, or obsessive-compulsive disorder, which features repetitive actions such as hand-washing to avoid germs.
OCD is thought to affect about 2 percent of the general population. The study didn’t examine OCD separately but grouped it with all anxiety disorders, seen in about 12 percent of college-aged people in the survey.
The overall rate of other disorders was also pretty similar among college students and non-students.
Substance abuse, including drug addiction, alcoholism and other drinking that interferes with school or work, affected nearly one-third of those in both groups.
Slightly more college students than non-students were problem drinkers — 20 percent versus 17 percent. And slightly more non-students had drug problems — nearly 7 percent versus 5 percent.
In both groups, about 8 percent had phobias and 7 percent had depression.
Bipolar disorder was slightly more common in non-students, affecting almost 5 percent versus about 3 percent of students.
I stumbled across this article from 2006 in the Health section of the NY Times regarding treatment and BPD. I think it illustrates that certain treatments can be more traumatic on the patient than others (or no treatment at all). Personally, I think it also could make the case for CBT/DBT (or another behavioral treatment) because those treatments are generally focused on effective skill-building for the here and now, rather than dredging up the past right away, which could cause more trauma to the patient.
May 30, 2006
Behavior
A Case in Point for the Maxim ‘Do No Harm’
By RICHARD A. FRIEDMAN, M.D.
Everyone knows that talking about your feelings is supposed to be good for you. In part, that’s probably why psychotherapy is widely viewed as a healthy pursuit. Conventional wisdom has it that self-knowledge is always a boon, and, like wealth, you can never have too much of it.
That’s what I thought until I met Helen.
Helen was a successful 52-year-old professional who had been married for 30 years. After watching “The Celebration,” a movie in which the family patriarch is publicly unmasked as a sexual predator by his children, Helen recovered what she believed were memories of sexual abuse by her father.
Over the course of several months, she felt depressed and angry and decided to start psychotherapy for the first time. Her therapist recommended twice-weekly sessions and encouraged her to discuss her childhood and memories of sexual abuse.
She became more depressed and anxious during the initial treatment, hardly unexpected given the traumatic material she had to deal with. But then something alarming began to happen.
Helen began to abuse alcohol, something she had never done before, and to cut her wrists superficially, an old behavior that she had stopped in her 20’s.
Helen was confused. If therapy was supposed to help her, why did she feel so much worse? What could explain the fact that this previously high-performing professional woman had become a serious alcohol abuser who was cutting her wrists several times a week with a razor?
The problem was that Helen had what psychiatrists call borderline personality disorder, and therapy had encouraged a process of self-exploration that proved toxic to her.
She did not have the psychological resources to deal with the intense emotions that this kind of therapy unleashed.
Borderline patients frequently use alcohol or drugs to try to stabilize their overly reactive moods, and they often injure themselves to relieve unbearable psychic pain.
In hindsight, it’s easy to see that this was just the wrong treatment for this particular patient. Yet even when she was given a more supportive treatment, aimed at helping her cope rather than delve into her feelings, she still floundered and didn’t function nearly as well as she did before having any therapy.
It will sound heretical coming from a psychiatrist, but there are some patients who feel worse and get worse when they are in psychotherapy. For some, the problem is getting the wrong type of treatment; for others, it may be the relationship with the therapist that is problematic, regardless of the specific treatment.
In an analysis of psychotherapy studies, Dr. Michael Lambert, a professor of psychology at Brigham Young University and a well-known expert in psychotherapy research, found that about 5 percent to 10 percent of patients deteriorated with psychotherapy.
This is not a trivial problem considering that 3.5 percent of all Americans were in psychotherapy each year from 1987 to 1997, according to a 2002 study published in The American Journal of Psychiatry by Dr. Mark Olfson of the College of Physicians and Surgeons of Columbia.
Although we are not very good at predicting which patients are likely to get worse with treatment, it’s not that hard to spot them once they are in therapy and things aren’t going well.
A few years back, one of my residents was treating a young man in psychotherapy who had great difficulty deciding what he wanted to do with his life.
He wasn’t depressed, but he was a very passive person.
It became clear that the patient was using the treatment not to understand his passivity, but to indulge it; he enjoyed talking about what he should do, but made no steps outside of therapy despite many attempts to address his behavior. We stopped his psychotherapy and referred him for vocational counseling.
The possible benefits of no treatment go beyond just patients who get worse in therapy. Some patients have been in psychotherapy for so long that it isn’t clear what the advantage of treatment is; in some of these cases, stopping therapy gives patients a chance to discover that they might do fine without it.
Others might seek treatment during a crisis or when they are grief-stricken. As painful as these situations can be, if people are generally healthy and have good social supports, they are likely just to feel better with time and probably don’t need any treatment at all.
At first blush, it might sound paradoxical — even uncaring — but sometimes the best treatment is no treatment at all.
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