Calvin and Hobbes -- Gritty Reboot

Texas Plumber's Used Pickup Falls into the Hands of Islamic Militants

The Ford F-250 is pretty badass.

Galveston Daily News

TEXAS CITY — A local plumber is being flooded with phone calls — and some threats — after a picture of one of his old company vehicles being used by Islamist militants in Syria was posted on Twitter.

                                                                                                                                                                                                                                                            

The picture was posted online by the Islamic extremist brigade Ansar al-Deen Front, according to a CBS News report. It shows a black pick-up truck with a Mark-1 Plumbing decal on the door and an anti-aircraft gun in the bed.

 

                                                                                   

Mark Oberholtzer, who has owned and operated Mark-1 Plumbing in Texas City for the past 32 years, confirmed it was his pickup truck in the picture. He said he no longer owned the vehicle and had no idea how it ended up in Syria."

Taxi Driver RomCom trailer

Cognitive therapy for whining (with Albert Ellis)

Given the choice, would you rather have had Albert Ellis, Aaron Beck, or Martin Seligman as your personal psychotherapist? My pick is Ellis, hands down. I love his sense of humor and no-b.s. attitude. With his New York accent and eyeglasses, I also get a positive transferential reaction between Ellis and my dad. Further, I agree with Ellis that many contemporary cases of"anxiety" or "depression" stem from people whining about not having been given everything they want as quickly as they want it.

The Yale Whiffenpoof song is not as famous as it was when the film clip was recorded, so here it is if you are interested (Ellis starts singing the parts from 1:18 on):

Nothing is funny to a psychiatrist...

...or to a clinical psychologist. This recent New Yorker cartoon makes a strong point about the potentially infantilizing effects of being medicated. But by suggesting that the goal of combined treatment (psychotherapy + medication) is being "happy," the cartoon is discordant with Freud's contention that the purpose of psychoanalysis is to transform uncommon misery into "common unhappiness." If the patient is "happy," why are they still in treatment? I like to think that a psychoanalyst would be more likely to see the patient's "happiness" as a medication effect (e.g., feeling more energized) and would thus want to titrate her off her meds and then get down to her core issues.

The cartoon made me wonder how many psychoanalysts also prescribe medication to their patients. It turns out that up to 90% of psychoanalysts also prescribe medication and that medication is used in about 30% of supervised training cases. From Gabbard (2005):

"The patient must be viewed simultaneously as a disturbed person and as a diseased central nervous system. The former view requires an empathic, subjective approach, whereas the latter demands an objective, medical model approach. The clinician must be able to shift between these two modes gracefully while remaining attuned to the impact of the shift on the patient" (p. 151).

Gabbard notes that patients sometimes feel like their doctors are "giving up on them" when they recommend medication. He also notes that clinicians and patients often disagree about the relative contributions of psychotherapy and medication. In my experience, patients are often too eager to attribute positive treatment gains to pharmacological effects. The psychological effects of medication are especially clear when patients report significant improvement within a day or two after starting SSRIs, or after taking homeopathic doses of their prescribed medications, or when they say that they "only take my Wellbutrin when I'm having a bad day."

Some quibbles: The doctor's chair is too far forward; his shoes are in the patient's peripheral vision and he should be completely out of view. (That way she will feel more free to say whatever comes to mind -- free associate -- without concern over his reactions.) There shouldn't be a painting in the patient's line of sight, either, because it will influence the free association. I do like how the facial tissues are just out of reach -- this isn't supportive therapy, bucko. And nice touch with the antimacassar.



From the excellent website of the American Psychoanalytic Association:

In psychoanalysis, the patient typically comes four times a week [!], lies on a couch, and attempts to communicate as openly and freely as possible, saying whatever comes to mind. These conditions create the analytic setting, which enables you to become more aware of aspects of your internal experience previously hidden. As you speak, hints of the roots of current difficulties that have been out of your awareness gradually begin to appear – in certain repetitive patterns of behavior, thought and emotion, in the subjects which you find hard to talk about, in the ways you relate to the analyst. The analyst helps to identify these patterns, and together you and the analyst refine your understanding of the patterns that limit you or cause you pain, and help you elaborate new and more productive ways of feeling, thinking and behaving. During the years [!] that an analysis takes place, you wrestle with these insights, going over them again and again with the analyst and experiencing them in your daily life, fantasies, and dreams. You and the analyst join in efforts not only to modify crippling life patterns and remove incapacitating symptoms, but also to expand your freedom to enjoy intimate relationships and professional and personal pursuits. Gradually, you will change in deep and meaningful ways; you may notice changes in your behavior, relationships and sense of self.
 

Lost in Medication

 

This piece by psychiatry resident Sarah Mourra appeared in The Atlantic on May 10, 2013.

Begin Excerpt

"In many places psychiatry has become a biological enterprise, with some psychiatrists even introducing themselves as "psychopharmacologists." In no other specialty does a physician define themselves by the medication that they use. As one of my psychiatry professors once commented, "I have never met an oncologist who says "I'm an onco-pharmacologist." Increasingly, we are convinced that medications are what make patients better -- and that if only they would stay on them, if only they would take them as we have prescribed them, if only they were on the right one or the right dose -- they would get better.

In reality the process of getting better is much more complicated. Medications can play a large role, but other factors are enormously important -- environment, sense of purpose and meaning, the person's perception of their illness, and their relationship with the people who treat them. Studies have shown that patients taking placebo who have a good relationship with their psychiatrist have better outcomes than patients taking the active drug who do not have that strong personal connection. In the outpatient setting, a well-trained psychiatrist will follow what's called the biopsychosocial treatment model -- which values the biological, psychological, and social aspects of a person in considering their treatment -- and consider these other parts of the patient's healing process, in addition to medication."

End Excerpt

Let's stop there for a moment. First of all, check out the Results section of the abstract that she linked to (Mckay, Imel, & Wampold, 2006. Psychiatrist effects in the psychopharmacological treatment of depression. Journal of Affective Disorders):

"The proportion of variance in the BDI scores due to medication was 3.4% (p < .05), while the proportion of variance in BDI scores due to psychiatrists was 9.1% (p < .05). The proportion of variance in the HAM-D scores due to medication was 5.9% (p < .05), while the proportion of variance in HAM-D scores due to psychiatrist was 6.7% (p = .053). Therefore, the psychiatrist effects were greater than the treatment effects."

This is data from a randomized double-blind placebo controlled clinical trial of an antidepressant. The psychiatrists were handing out meds to depressed patients, giving placebos to some and active drugs to others. What is stunning to most people is that the degree of your recovery from depression (as measured by BDI and HAM-D scores) was affected more by which psychiatrist you happened to be treated by than whether he or she gave you "real" or "fake" drugs. However, this study (don't you love how we always write, "studies have shown" and then we only cite one study to support our statement?) doesn't say anything about "strong personal connections" between psychiatrists and patients.

For the most part, the patient encounters in this study consisted of the standard "15 minute med checks." Thus there was scant opportunity to build the "strong personal connections" that Dr. Mourra believes were formed, and which she believes explain the findings. But the quality of the "therapeutic alliance" between doctor and patient was not measured in this study. Therefore, it is just as possible that other factors, also not measured by the researchers, played a role, e.g., whether diplomas and certificates were prominently displayed in the doctor's office, whether or not a male psychiatrist wears a tie, the quality of the magazines in the waiting room, etc. You can't just add this study to the ample literature that shows that therapeutic alliance is the most important predictor of psychotherapy outcome (see here, and here, for recent examples).

So, yes, it matters which psychiatrist you happen to see. Some psychiatrists seem to be more effective than others, and their patients tend to do better whether or not the patient is receiving active or placebo medication. But the reason for this is not necessarily because some psychiatrists have formed "strong personal connections" with their patients while others did not. It could be that some of the less effective psychiatrists were non-native English speakers.

 

 

"Now do you understand why you stay awake all night, horrified that you are wasting your life?"

Continue Excerpts

"Often under pressure from insurance companies, inpatient psychiatric units experience a tremendous push to medicate patients quickly and discharge them as soon as possible....Often involving numerous rotating caregivers working in shifts, moonlighters, or trainees on one rotation and off to another, patients often complain, "I only saw my doctor for ten minutes!" ....Overpopulated psych units resulting from hospitals trying to keep out of the red often lead to burned out staff members who would rather silence a psychotic, agitated, or complaining patient with medication than sit down and talk to them. ... I remain baffled by the expectation that patients could easily begin the process of recovery from mental illness on most inpatient psychiatric units....These units are designed to keep patients safe and prevent adverse outcomes like a suicide in the hospital or emergency room. However, the therapeutic value of the physical setting is often overlooked as strapped hospital budgets prioritize other needs.

Fed up with the apparent "mill" of psychiatric hospitalization, a process that seemed to lose the person in the cycle of checkboxes and protocols, I wondered out loud to one of my supervisors whether anything like the old asylums existed. Though these institutions had many flaws, it seems as though things have swung too far the other way. The value of fresh air, therapeutic work, and a community of peers seems to have crumbled away in our quest for quicker and faster discharges and a focus on crisis management.

...

This isn't to say that people don't need to be on medication -- but this psychopharmacological myopia is dangerous in that most psychiatrists of my generation pay lip service to the "psychosocial" part of the biopsychosocial treatment model while failing to put it into practice. This is no fault of our own. I come from a generation of psychiatrists who will never see someone come into a hospital, be taken off all medications, and get better. And for many in my generation, if you don't see it, you won't believe it's possible."

End Excerpts

The often repeated quip is that psychiatry follows the "bio-bio-bio" model, rather than the biopsychosocial model. One of my recent patients was told by her psychiatrist (she came to me because of her dissatisfaction with her medication treatment) that her depression was "100% biological" and could only be treated with medication. I do not doubt that he believes this. Most psychiatric residents don't get much training in psychotherapy (compared to clinical psychologists) and fewer psychiatrists spend much time practicing psychotherapy (44% of psychiatric office visits involved psychotherapy in 1997 versus 29% in 2005; source). This response by Ronald Pies to this rather damning New York Times article seems rather weak to me, in that the type of "psychotherapy" provided by psychiatrists he is talking about seems to involve occassionally listening to patients talk about their lives ("supportive psychotherapy") and not the type of  focused, consistent (e.g., 16-24 weekly 50-minute sessions) psychotherapy that I and most of my clinical psychologist colleagues practice.

In the comments section of The Atlantic article, someone called bystander sums the situation up even better than the author of the article:

"It's a weird moment in science. On the one hand you have physicists proclaiming to have answered the ultimate questions posed by the universe, human spirituality, etc. etc. On the other hand, psychiatry, which should be the application of all that insight to the problem of healing people psychologically, is floundering from what looks from the outside like the obvious blunder of thinking that a human being is nothing more than a mass of chemical reactions and physical processes. (That's what the near-exclusive reliance on medication means, right? If you think a human being is a mass of chemicals, then a psychological problem is a chemistry problem, and a chemistry problem calls for a chemical solution.)

Here's hoping the scientific and medical communities get a does of common sense and humility and realize that the spiritual and psychological sides of human being are far from having been explained, let alone explained away, by science, physics and chemistry, and that some old-fashioned common sense, empathy, emotional contact and yes, spiritual insight would go a long way to correcting this weird and weirdly arrogant imbalance."
 

I'll let Abe Maslow have the last word:

I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.

• The Psychology of Science: A Reconnaissance (1966), Ch. 2, p. 15  

 

 

 

 

 

Helping People with Paranoid Schizophrenia

Panelists discuss ways to care for the nation's paranoid schizophrenics. Click here for video.

 

So you want to be a clinical psychologist...

When this was first posted, a lot of people that I had trained with while I was in grad school forwarded the link to me. It seems to resonate with a lot of people in the field, although it is terribly cynical and potentially demoralizing. So, if you are an undergraduate who aspires to become a clinical psychologist, don't let this animated video discourage you. At the same, realize that in humor there is often truth. And also realize that by now similiar animations have been created for virtually any profession you can think of.

"Your mother will cry and ask you why you did not become a real doctor."

 

 

I don't think it is true that "when you are a clinical psychologist people always think that you are crazy, so you always have to be extra nice so people don't think you're crazy." In my experience, it is more the case that when you are a clinical psychologist, people you meet outside of work worry that you are going to detect (or have already detected) just how crazy they really are. Most people are aware (to varying degrees) that they are not quite "normal," and they spend a lot of time and energy trying to conceal this from others. Clinical psychologists are fully aware that no one is as normal as they appear to be and that everyone has aspects that are just plain weird. Other people realize that they themselves are weird, and they mistakenly believe that everyone else is normal.