John M. Talmadge, M.D.

A Blog Covering Many Topics

Families, Pressure, & Stress

Working families are having difficulty bearing the stress and strain of modern living, despite the many advances that make our lives (so we say) easier and better. The problem, according to a Pew Research study cited in the New York Times, is "the difficulty of balancing it all." The "stress gap" is also notable owing to the correlation with race and education. White college-educated parents are significantly more likely to say that balancing family life and the workplace is difficult. As more mothers have joined the workforce, the share of two-parent households in which both parents work full time now stands at 46%, up from 31% in 1970. At the same time, the share with a father who works full time and a mother who doesn’t work outside the home has declined considerably; 26% of two-parent households today fit this description, compared with 46% in 1970, according to the Pew Research Center analysis of Current Population Survey data.

Working mothers (60%) are somewhat more likely than fathers (52%) to say it’s difficult for them to balance work and family, and this is particularly the case for mothers who work full time. In fact, one-in-five full-time working moms say balancing the two is very difficult for them, compared with 12% of dads who work full time and 11% of moms who work part time.

Overall, relatively few working parents (9%) say parenting is stressful for them all of the time. But a significant share say that parenting is stressful all or most of the time, and that sentiment is much more common among parents who say they have difficulty balancing work and family life (32% compared with 15% of those who say achieving a work-life balance is not difficult for them). In addition, four-in-ten (39%) of those who say it is hard for them to balance their responsibilities at work and at home find being a parent tiring at least most of the time; of those who say it’s not difficult for them to strike a balance, 23% say being a parent is tiring at least most of the time.

Graphic about working parents priorities

Fifty-six percent of all working parents say the balancing act is difficult, and those who do are more likely to say that parenting is tiring and stressful, and less likely to find it always enjoyable and rewarding. For example, half of those who said the work-family balance was not difficult said parenting was enjoyable all the time, compared with 36 percent of those who said balance was difficult.

In her 1989 book The Second Shift, the sociologist Arlie Russell Hochschild described the double burden employed mothers face because they are also responsible for housework and child care. Last year she said that despite some changes in society, the workplace had not changed enough to alleviate the problems. In another widely praised book, All Joy and No Fun, the journalist Jennifer Senior described how little had improved: Working parents face similar stresses, but they are now exacerbated by the expectations of modern parenthood and shared by fathers, too.

Senior draws on the psychologist Daniel Kahneman’s distinction between the “experiencing self” that exists in the present moment and the “remembering self” that constructs a life’s narrative. “Our experiencing selves tell researchers that we prefer doing the dishes — or napping, or shopping, or answering emails — to spending time with our kids. But our remembering selves tell researchers that no one — and nothing — provides us with so much joy as our children. It may not be the happiness we live day to day, but it’s the happiness we think about, the happiness we summon and remember, the stuff that makes up our life-tales.” She talks about parents’ pride in their children, not only in their accomplishments but even in their basic development as human beings, their growth into kindness and generosity. “Kids may complicate our lives,” she writes. “But they also make them simpler. Children’s needs are so overwhelming, and their dependence on us so absolute, that it’s impossible to misread our moral obligation to them. We bind ourselves to those who need us most, and through caring for them, grow to love them, grow to delight in them, grow to marvel at who they are.”

Job Burnout: The Basics

Many of us who found sobriety and recovery along the way also used alcohol and/or drugs to cope with unhappiness at work. The excellent Mayo Clinic website has good advice about identifying and dealing with "job burnout," a state of physical, emotional or mental exhaustion combined with doubts about one's competence and the value of one's work. Before resorting to pills and alcohol to solve this unhappy state of mind, it's better to take inventory and see if burnout is really the problem. Here are some tips from the experts at Mayo:

Ask yourself the following questions:
• Have you become cynical or critical at work?
• Do you drag yourself to work and have trouble getting started once you arrive?
• Have you become irritable or impatient with co-workers, customers or clients?
• Do you lack the energy to be consistently productive?
• Do you lack satisfaction from your achievements?
• Do you feel disillusioned about your job?
• Are you using food, drugs or alcohol to feel better or to simply not feel?
• Have your sleep habits or appetite changed?
• Are you troubled by unexplained headaches, backaches or other physical complaints?
If you answered yes to any of these questions, you may be experiencing job burnout. Be sure to consult your doctor or a mental health provider, however. Some of these symptoms can also indicate certain health conditions, such as a thyroid disorder or depression. Several times a year I encounter a patient suffering from low thyroid, iron deficiency anemia, Vitamin D deficiency, and other conditions that contribute to fatigue and burnout.

Discover if you're at risk of job burnout — and what you can do
when your job begins to affect your health and happiness.

Job burnout can result from various factors, including:
Lack of control. An inability to influence decisions that affect your job — such as your schedule, assignments or workload — could lead to job burnout. So could a lack of the resources you need to do your work.
Unclear job expectations. If you're unclear about the degree of authority you have or what your supervisor or others expect from you, you're not likely to feel comfortable at work.
Dysfunctional workplace dynamics. Perhaps you work with an office bully, you feel undermined by colleagues or your boss micromanages your work. These and related situations can contribute to job stress.
Mismatch in values. If your values differ from the way your employer does business or handles grievances, the mismatch may eventually take a toll.
Poor job fit. If your job doesn't fit your interests and skills, it may become increasingly stressful over time.
Extremes of activity. When a job is always monotonous or chaotic, you need constant energy to remain focused — which can lead to fatigue and job burnout.
Lack of social support. If you feel isolated at work and in your personal life, you may feel more stressed.
Work-life imbalance. If your work takes up so much of your time and effort that you don't have the energy to spend time with your family and friends, you may burn out quickly.


You may be more likely to experience job burnout if:
• You identify so strongly with work that you lack a reasonable balance between your work life and your personal life
• You try to be everything to everyone
• You work in a helping profession, such as health care, counseling or teaching
• You feel you have little or no control over your work
• Your job is monotonous

Ignored or unaddressed job burnout can have significant consequences, including:
• Excessive stress
• Fatigue
• Insomnia
• A negative spillover into personal relationships or home life
• Depression
• Anxiety
• Alcohol or substance abuse
• Heart disease
• High cholesterol
• Type 2 diabetes, especially in women
• Stroke
• Obesity
• Vulnerability to illnesses

Don't let a demanding or overwhelming job undermine your health.

Remember, if you think you may be experiencing job burnout, don't ignore your symptoms. Consult your doctor or a mental health provider to identify or rule out any underlying health conditions.If you're concerned about job burnout, take action. To get started:

  • Manage the stressors that contribute to job burnout. Once you've identified what's fueling your feelings of job burnout, you can make a plan to address the issues.
  • Evaluate your options. Discuss specific concerns with your supervisor. Perhaps you can work together to change expectations or reach compromises or solutions. Is job sharing an option? What about telecommuting or flexing your time? Would it help to establish a mentoring relationship? What are the options for continuing education or professional development?
  • Adjust your attitude. If you've become cynical at work, consider ways to improve your outlook. Rediscover enjoyable aspects of your work. Recognize co-workers for valuable contributions or a job well done. Take short breaks throughout the day. Spend time away from work doing things you enjoy.
  • Seek support. Whether you reach out to co-workers, friends, loved ones or others, support and collaboration may help you cope with job stress and feelings of burnout. If you have access to an employee assistance program (EAP), take advantage of the available services.
  • Assess your interests, skills and passions. An honest assessment can help you decide whether you should consider an alternative job, such as one that's less demanding or one that better matches your interests or core values.
  • Get some exercise. Regular physical activity, like walking or biking, can help you to better deal with stress. It can also help get your mind off work and focus on something else.
  • Pay attention to your use of alcohol, pills, or other "stress relievers." Although booze and drugs can provide temporary relief, neuroscience tells us that the misuse of alcohol or intoxicants is bad for your brain. It's better to get proper help from a qualified professional.
The bottom line? Keep an open mind as you consider the options. Don't let a demanding or unrewarding job undermine your health.

News Flash! Interesting Articles...

Mindfulness Therapy: Alternative to Antidepressants

Many psychiatrists like me recommend mindfulness and cognitive therapy to our patients. These two approaches work well together because psychotherapy ("talk therapy" is best when individualized rather than using a "cookbook" approach. One size does not fit all. The legendary British medical journal The Lancet (April 2015 includes a recent scientific paper showing that mindfulness-based cognitive therapy (MBCT) could provide an alternative non-drug treatment for people who do not wish to continue long-term antidepressant treatment. This is one example of brain science at its best.


Mindfulness-based cognitive therapy aims to change the way people think and feel about their experiences. How we think affects how we feel. And the use of mindfulness practice is relatively easy for most people. Just 10-15 minutes two or three times daily makes a difference. The current study compares MBCT with maintenance antidepressant medication for reducing the risk of relapse in depression. The results are encouraging.

The study aimed to establish whether MBCT is superior to maintenance antidepressant treatment in terms of preventing relapse of depression. Although the findings show that MBCT isn't always more effective than maintenance antidepressant treatment in preventing relapse of depression, the results, combined with those of previous trials, suggest that MCBT may offer similar protection against relapse or recurrence for people who have experienced multiple episodes of depression, with no significant difference in cost.

"Mindfulness gives me a set of skills which I use to keep well in the long term. Rather than relying on the continuing use of antidepressants mindfulness puts me in charge, allowing me to take control of my own future, to spot when I am at risk and to make the changes I need to stay well." — Study Participant

MBCT builds on the insight that when people with a history of depression experience even a brief period of feeling low they tend to be especially vulnerable to negative thinking. That negative thinking is often accompanied by what’s known as “processing biases”: worrying about past problems, for example, or returning to unpleasant memories. Thinking like this raises the risk of a full-blown depressive episode.

MBCT focuses on helping people to become more aware of these thoughts and feelings, and thus better able to gain distance from them. As its founders put it: “We discover that difficult and unwanted thoughts and feelings can be held in awareness, and seen from an altogether different perspective – a perspective that brings with it a sense of warmth and compassion to the suffering we are experiencing.”

Talk Therapy? Medication?

"We are more than a brain in a jar," Dr. Richard Friedman wrote recently in the New York Times. In his timely article about psychiatry, he goes on to say, "Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front." He points out that billions are spent on pharmaceutical research — the quest for the magic pills that will change the way we think and feel — but comparatively little money goes to psychotherapy research.

image of poster about pills

I am an old-timer, and when my generation trained in psychiatry virtually all of us planned on being psychotherapists who were well educated in the use of medication as an adjunct to talk therapy. All psychiatrists I knew back then had been in psychotherapy themselves; personal therapy was considered part of becoming a competent clinician: "Physician, know thyself."

If a psychiatrist has a limited vocabulary, and can't conjugate nouns and verbs, how can they possibly communicate with patients?

Research shows that when psychotherapy and medication are both available, the combination is synergistic. It's like saying 1 + 1 = 3. Today, however, fewer than 10% of psychiatrists are trained and skilled in psychotherapy. My opinion is that this is why a good psychiatrist is very hard to find. I have been teaching young psychiatrists for over thirty years, and I have been a training director in one of our finest medical schools, and I can say with authority that many psychiatrists coming out today get failing grades when it comes to important skills like writing, speaking, and communicating clearly. I'm talking about basic errors in English grammar, syntax, and sentence structure — the stuff most people should learn by the time they enter high school! If a psychiatrist has a limited vocabulary, and can't conjugate nouns and verbs, how can they possibly communicate with patients? This is one reason that psychiatrists today are, in general, poor psychotherapists with little interest in what talk therapy has to offer.

Writing in a medical chart is similar to text messaging. It's easy, and grammar doesn't count. In fact, the modern electronic medical record discourages thoughtful writing, just like text messaging does. A good psychiatrist should not only speak well and write well. A good psychiatrist should be a superior thinker and communicator. Every doctor should have a big sign on the wall behind the chair where the patient is sitting: "DOCTOR, YOUR PATIENT IS TRYING TO TELL YOU SOMETHING!"


Here's Dr. Friedman again: "With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s."

"Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective."

Prescribing a pill is easier and cheaper than offering the patient psychotherapy. Psychiatrists are paid more to prescribe pills than to counsel with patients. It is understandable, then, that the incentive is to see five patients in a single clinic hour. This saves insurance companies a lot of money. Many insurance companies will not even pay for psychotherapy with a qualified psychiatrist. And think about this: if a patient doesn't like the psychiatrist, there are fewer repeat or return visits. The winners are the insurance companies.

Dr. Friedman is also critical of trends in research, not because they are wrong, but because of simplistic logic. "The doubling down on basic neuroscience research" he says, "seems to reflect the premise that if we can unravel the function of the brain, we will have a definitive understanding of the mind and the causes of major psychiatric disorders." He points to an editorial in May in one of the most respected journals in our field, JAMA Psychiatry, emphasizing the brain but not mentioning the mind, the complexity of mental illness, or anything about how psychotherapy scientifically helps the brain. Friedman believes that "an undertaking as ambitious as unraveling the function of the brain would most likely take many years. Moreover, a complete understanding of neurobiology is unlikely to elucidate the complex interactions between genes and the environment that lie at the heart of many mental disorders."

"Anyone who thinks otherwise should remember the Decade of the Brain, which ended 15 years ago without yielding a significant clue about the underlying causes of psychiatric illnesses."
—Professor and Psychiatrist Richard Friedman

Dr. Friedman's article generated a number of replies, including this one from Christopher Lukas, a noted author:

"Over the years, I have had talking therapy for my depression and post-traumatic stress disorder, and I don’t believe I would be alive were it not for those sessions. I have also taken a whole range of medications for depression and find that psychotherapy outweighs the benefits of any of those drugs.

"Some psychiatrists and some patients think that drugs are better because they work like aspirin: Take two and call me in the morning. But, as Dr. Friedman pointed out, and as I have experienced, other patients find doses of talking therapy can work well if we’re patient and if we understand that many emotional problems may take time to go away.

"Persistence, willingness to give yourself over to the process and willingness to change therapists if the talk isn’t helping you: These are key to talk therapy’s benefits."


The comments by Lukas remind me of something I pointed out to a patient just last weekend. Asking about Alcoholics Anonymous, she wanted to know what it takes to succeed in finding sobriety through AA. "An easy way to think about it," I said, is to remember the three letters H-O-W." The old AA acronym stands for "honesty, open-mindedness, and willingness."

Another writer, who is a physician herself, also agreed with Dr. Friedman:

"For the past 30 years psychotherapy has been given short shrift as drug therapy has become the treatment of choice. There are many reasons for this, but the most powerful are economic.

"Doctors can manage medication for many more patients in a day than they can treat with psychotherapy. More important, pharmaceutical companies, which profit from the drug sales, support research, thus providing funds to psychiatry departments that receive no similar support for psychotherapy research.
Sadly, in the past generation or two there has been a huge loss in professional expertise as fewer psychiatry residency programs provide top-notch psychotherapy education and supervision.

"Twenty-eight years ago I went to medical school planning a career in child psychiatry. My interest had been primed by fascinating conversations I’d heard in high school between my father, a psychoanalyst, and his colleagues.
My medical school psychiatry rotation was a disappointment. There was no attempt to solve the riddles of patients’ emotions and behavior, only the adjustment of medication doses to treat symptoms. Still wanting to solve puzzles, I chose a career in radiology.

"When my father died, I was tremendously moved to hear some of his patients who attended his funeral tell me how the treatment he provided had profoundly changed their lives. Psychotherapy should be an integral part of psychiatric training."

Since I do both — I am a psychotherapist who prescribes medication when appropriate — it's understandable that I agree with Dr. Friedman. It's also true that I practice this way because that approach provides the best care for the brain, the mind, and the whole person.

The Adderall Phone Call Trend

At least twice a week, and more often during certain times of the year, I get calls from college students looking for a doctor who prescribes medication for attention deficit disorder. I also get a lot of calls asking for sedatives like Xanax and Klonopin. Although these medications can be very helpful, my experience is that most of these students are not really suffering from ADD, and I tell most of them (not all) that I am not in the business of managing Schedule II drugs. Schedule II is the class of medications most closely monitored by the Drug Enforcement Administration. Special numbered prescription forms are mandatory and required, and the doctor found guilty of bad prescribing may likely lose his license to practice.

The underground trade in stimulants is massive. People will pay $20 for a single pill on the street.

ADD medications like Adderall and Ritalin are stimulants, amphetamines or amphetamine-related compounds. They can be miraculously helpful when the doctor has the right diagnosis and prescribes them appropriately. I am a big believer in the value of such medications, because they work. I also know from experience that they can be terribly abused.

Here are some tips from the American Academy of Child and Adolescent Psychiatry:

Many students with Attention Deficit Hyperactivity Disorder (ADHD) attend college. College students with ADHD face a number of challenges, including choosing a supportive school and community where they can find and access medical services, get help with organizing their schedule and life, and succeed academically

Most people with ADHD are diagnosed before college. However, some people may not recognize the signs and symptoms of ADHD until they are at college. Trying to balance school work and the freedom of living away from home for the first time may be challenging. It can be natural to feel unfocused, distracted, overwhelmed, or disorganized when attending college. However, if these issues have caused significant problems in the past and are getting in the way of current functioning, the student may have ADHD.

If a student is struggling, it may be helpful to seek consultation with a qualified mental health professional. The diagnosis of ADHD is made based on a comprehensive clinical assessment. This may include information from multiple sources, including rating scales, getting history from the student, family, or past teachers if possible. There is no single test (brain imaging, blood testing, or psychological testing) that can reliably diagnose ADHD. Research shows that medication is the most effective treatment for ADHD. Cognitive-behavioral therapy, social skills training, and academic support can also be helpful.

There are many ways to successfully manage ADHD before and during college.

Preparing for and Staying Organized While at College

Consider the best college environment to meet your needs, such as class size, workload, academic calendar, and availability of support services. Resources to help you find the best college include: high school counselors, parents, friends who are in or have attended college, and national ADHD organizations or websites.

Learn about the medical services available at colleges before choosing where to go. Some college and university health centers do not prescribe ADHD medications. You may need to find a doctor in the surrounding community. Think about the transportation options and ease of access to that provider.

Talk with your doctor about how to best manage your medications when at college. Do not make changes in your medication without consulting your doctor. Ask your current doctor and the doctor at college to coordinate care. It is also helpful to have a history of your medications and your response to those medications for your new doctor.

If you have used tutors or support before college, think about continuing at college, at least for a little while.

If you need specific support or accommodations, register at the college disability office. If you have a summary of treatment or any psychological tests that were done within the last 3 years, bring them to the visit.

Practice using planners, calendars, or scheduling apps while still in high school. The demands on time management and organization increase greatly in college. Even if your parents helped you in the past, it is important to learn to do it yourself.

Managing Medications at College

Many medications prescribed for ADHD have to be monitored regularly. While at college, you need to schedule and keep your own medical appointments. Changes to your medication should only be made after talking with your doctor.

Learn how to use pharmacy services. Pay attention to prescription start dates and expiration dates. Many medications prescribed for ADHD are “controlled substances” so states may have additional rules on how these medicines can be provided, including limits on how often prescriptions can be refilled.

Taking medication that is not prescribed for you, sometimes called “diversion” or “academic doping,” is illegal and unsafe. Your medications were prescribed by your doctor who knows you and your medical history. They should only be taken by you. There are serious cardiac, neurological, and psychological risks of misusing ADHD medications. There can also be serious risks to mixing medications with alcohol or other drugs.

Keep medications safely stored or hidden to protect against theft. If medications are stolen, report it to campus or local police.
Adjusting to the academic, social, and organizational demands of college is difficult for most students. It can be especially difficult for students with ADHD. Arranging for support from medical and school professionals can help students with ADHD have a successful college experience, as well as a long career after graduation.

Should Children Take Antipsychotic Drugs?

A current article in Scientific American addresses a serious problem in psychiatry: the overmedication of children, not only by psychiatrists but also by pediatricians and family physicians. Some years ago I reviewed the case of a child who was admitted to a psychiatric hospital, and at the time of the admission this five-year-old was on three psychiatric medications. Five days later the child was discharged on five medications, four of which the child was not taking on Day One of the hospitalization. I was astonished. In the 1980's, when I was a medical director in a specialty hospital treating young children, these kids would stay with us for months, not days. The entire first month was devoted to getting the diagnosis right and developing a coherent treatment plan. Our assumption, which is still true today, is that the doctor and the team must get to know the patient.

According to Scientific American: "Modern antipsychotic drugs are increasingly prescribed to children and adolescents diagnosed with a broad variety of ailments. The drugs help to alleviate symptoms in some disorders, such as schizophrenia and bipolar disorder, but in others their effectiveness is questionable. Yet off-label prescribing is on the rise, especially in children receiving public assistance and Medicaid. Psychotic disorders typically arise in adulthood and affect only a small proportion of children and adolescents. Off-label prescriptions, however, most often target aggressive and disruptive behaviors associated with attention-deficit hyperactivity disorder (ADHD). “What's really concerning now is that a lot of this prescription is occurring in the face of emerging evidence that there are significant adverse effects that may be worse in youth than in adults,” says David Rubin, a general pediatrician and co-director of PolicyLab at Children's Hospital of Philadelphia. Here we review the evidence for the effectiveness of antipsychotic medications commonly prescribed for five childhood conditions. But do the benefits outweigh the risks?" To read the entire article, click here.

The mental health system can sometimes be complicated and difficult for parents to understand. A child's emotional distress often causes disruption to both the parent's and the child's world. Parents may have difficulty being objective. They may blame themselves or worry that others such as teachers or family members will blame them.

If you are worried about your child's emotions or behavior, you can start by talking to friends, family members, your spiritual counselor, your child's school counselor, or your child's pediatrician or family physician about your concerns. If you think your child needs help, you should get as much information as possible about where to find help for your child. Parents should be cautious about using the internet as their only source of information and referral.

Bogus: Dr. Oz

Medical students and residents frustrated with bogus advice from doctors on TV have, for more than a year, been asking the American Medical Association to clamp down and "defend the integrity of the profession."

This is an issue I have addressed before on this blog where my focus has been on quackery associated with the use of expensive neuroimaging or "brain scans" claiming to diagnose a variety of psychiatric problems like attention deficit disorder, addictions, and mood problems. Although neuroimaging is very promising, getting a scan does not change diagnosis or treatment for these kinds of disorders. One of the egregious offenders is Dr. Daniel Amen, perhaps the best known psychiatrist in America, whose self-produced PBS specials air widely on public television and promote his unproven claims about scans. Although Amen claims that his theories are based on thousands of cases, experts in the field have widely condemned his misrepresentation of the facts.

The AMA is finally taking a stand on quack doctors who spread pseudoscience in the media.

The AMA will look at creating ethical guidelines for physicians in the media, write a report on how doctors may be disciplined for violating medical ethics through their press involvement, and release a public statement denouncing the dissemination of dubious medical information through the radio, TV, newspapers, or websites.The move came out of the AMA's annual meeting in Chicago this week, where medical students and residents pushed the AMA after noticing that the organization was mostly silent during the recent public debates about the ethics of Dr. Oz sharing unfounded medical advice on his exceptionally popular TV show.

"Dr. Oz has something like 4 million viewers a day," student representatives said. "The average physician doesn't see a million patients in their lifetime. That's why organized medicine should be taking action."

Last summer, Oz was called before a Senate subcommittee on consumer protection, where the senator in charge, Claire McCaskill (D-MO), asked him to explain his use of "flowery" language to champion weight loss fixes that don't actually work and then admonished him for endorsing a rainbow of supplements as potential "belly blasters"and "mega metabolism boosters." As McCaskill put it, "The scientific community is almost monolithic against you in terms of the efficacy of the three products you called 'miracles.'"

In December, a British Medical Journal study examined the health claims showcased on 40 randomly selected episodes of the two most popular internationally syndicated health talk shows — The Dr. Oz Show and The Doctors — and found that about half of the recommendations either had no evidence behind them or actually contradicted the best available science.

In January, investigations into The Dr. Oz Show by the Federal Trade Commission showed that at least one of Oz's miracle-touting guests used the program as a platform to deceive audiences and sell products.

In April, a high-profile group of physicians and academics questioned Oz's faculty position at Columbia University and wrote in a letter to the medical school dean: "Dr. Oz is guilty of either outrageous conflicts of interest or flawed judgments about what constitutes appropriate medical treatments, or both." The same month, Oz responded to his critics by accusing them of having conflicts of interest and defending his civil liberties. "I know I have irritated some potential allies," he wrote in Time magazine. "No matter our disagreements, freedom of speech is the most fundamental right we have as Americans. We will not be silenced."

What Dr. Oz does not understand is that questions about ethics are not questions about "free speech." By his logic, a doctor can say virtually anything, make any claim, asserting that he or she has the right to freedom of speech. This is a terrible kind of logic, and it makes no sense at all.

Then again, many claims made by Dr. Oz make no sense, either.

One Nation, Under Sedation

In 2012, Medicare’s massive prescription drug program didn’t spend a penny on popular tranquilizers such as Valium, Xanax and Ativan. The following year, it doled out more than $377 million for the drugs.

Houston, we have a problem. For the full story, click here.

The distinguished addiction specialist Charles O'Brien, M.D., authored a paper in 2005 discussing the risks of benzodiazepine abuse. The summary of his article states: "Although benzodiazepines are invaluable in the treatment of anxiety disorders, they have some potential for abuse and may cause dependence or addiction. It is important to distinguish between addiction to and normal physical dependence on benzodiazepines. Intentional abusers of benzodiazepines usually have other substance abuse problems. Benzodiazepines are usually a secondary drug of abuse-used mainly to augment the high received from another drug or to offset the adverse effects of other drugs. Few cases of addiction arise from legitimate use of benzodiazepines. Pharmacologic dependence, a predictable and natural adaptation of a body system long accustomed to the presence of a drug, may occur in patients taking therapeutic doses of benzodiazepines. However, this dependence, which generally manifests itself in withdrawal symptoms upon the abrupt discontinuation of the medication, may be controlled and ended through dose tapering, medication switching, and/or medication augmentation. Due to the chronic nature of anxiety, long-term low-dose benzodiazepine treatment may be necessary for some patients; this continuation of treatment should not be considered abuse or addiction."

Image of poster dangers of benzodiazepines

Brain Scan Scams: Amen!

At least once a week I am asked about neuroscience and brain scans, usually by someone baffled by a psychiatric problem. I addressed "brain scams" in a blog post here back in April, and I've found another well-done article from The Washington Post describing the fame and the quackery of Dr. Daniel Amen, known for his self-produced PBS television shows and his many pseudoscientific books. Dr. Amen, who lives in a $4M home in California, is the poster child for what is worst in psychiatry. Although Amen has his admirers, the leaders of American psychiatry are not among his fans. The following paragraphs are excerpted and edited from the Washington Post article. The bottom line is this: There are situations, including some brain injuries, where a brain scan can be helpful in making a diagnosis. Brain scans today, however, cannot diagnose psychiatric disorders; nor do these expensive scans change the course of proper psychiatric care.

What the reader should understand is that Dr. Amen, like many promoters of fraudulent "cures," appeals to people who are vulnerable to snake-oil promotions and great salesmanship. He has even hornswoggled fellow entrepreneurial genius Rick Warren, best known for The Purpose Driven Life, and pastor of the Saddleback Church in California. Warren designated Amen as official guru for health and nutrition at his mega-church.

Few top researchers and scientists say that SPECT is anything but a research tool of limited clinical use in identifying strokes, brain injuries and the like. It is helpful in group studies, to say broad things about groups of patients, but not specific things about individual patients. And, researchers say, SPECT has largely since been surpassed by technologies such as PET and functional MRIs, which give images of far greater clarity. It’s no longer viewed as cutting edge.

The APA first debunked many of Amen’s SPECT claims in a 2005 report. In 2008, Carlat, the Tufts professor and author, went to California to test Amen’s clinic. He then wrote, in Wired Magazine, that the black-clad Amen looked “more like a Miami maitre d’ than a psychiatrist,” that the SPECT scan was “spectacularly meaningless” and that Amen’s analysis of it reminded him of a “shrewd palm reader.”

In 2010, Thomas Insel, director of the NIMH, wrote on his blog that while the technology “might be playing in prime time on some TV infomercials, brain-imaging experts say we’re not quite there yet.” Earlier this year, Anissa Abi-Dargham, a highly regarded professor of clinical psychiatry and radiology at Columbia who has done extensive work with brain imaging, spoke at an APA symposium on the limits of SPECT. She listened to Amen’s hour-long lecture there. Reached by phone recently, she said: “Had I known what this was, I would have never agreed to be part of it. It was not a scientific debate. It was propaganda for his clinics.”

No major research institution takes his SPECT work seriously, none regards him as “the number one neuroscience guy,” and his revelations, which he presents to rapt audiences as dispatches from the front ranks of science, make the top tier of scientists roll their eyes or get very angry. “In my opinion, what he’s doing is the modern equivalent of phrenology,” says Jeffrey Lieberman, APA presidentelect, author of the textbook “Psychiatry” and chairman of Psychiatry at Columbia University College of Physicians and Surgeons. (Phrenology was the pseudoscience, popular in the early 19th century, that said the mind was determined by the shape of the skull, particularly its bumps.) “The claims he makes are not supported by reliable science, and one has to be skeptical about his motivation.” “I think you have a vulnerable patient population that doesn’t know any better,” says M. Elizabeth Oates, chair of the Commission on Nuclear Medicine, Board of Chancellors at the American College of Radiology, and chair of the department of radiology at the University of Kentucky.

“A sham,” says Martha J. Farah, director of the Center for Neuroscience & Society at the University of Pennsylvania, summing up her thoughts on one of Amen’s most recent scientific papers. “I guess we’re all amateurs except for him,” says Helen Mayberg, a psychiatry, neurology and radiology professor at Emory School of Medicine and one of the most respected researchers into depression and brain scanning. “He’s making claims that are outrageous and not supported by any research.” “I can’t imagine clinical decisions being guided by an imaging test,” says Steven E. Hyman, former director of the National Institute of Mental Health and current director of the Stanley Center for Psychiatric Research at the Broad Institute of MIT and Harvard.

The APA, in fact, has twice issued papers that dispute “claims being made that brain imaging technology ... was useful for making a clinical diagnosis and for helping in treatment selections.” The most recent paper was the work of 12 doctors who spent three years assessing the latest research. The summary: “There are currently no brain imaging biomarkers that are currently clinically useful for any diagnostic category in psychiatry.”

Four years ago, Robert Burton, the author and former associate chief of the department of neurosciences at the University of California at Mount Zion Hospital, wrote a harsh article on Salon.com about Amen’s work. The headline was “Brain Scam.” When recently told that Amen was still in business and grossed $20 million last year, Burton asked for the dollar figure to be repeated. “Oh, my God,” he said. “Just oh, my God. At some point this gets to be obscene — that’s just my bias — but oh, my God.”

To read the entire article from The Washington Post, click here.

In 2010, concerns about Dr. Amen and the "brain scam industry" reached a boiling point. In The American Journal of Psychiatry, my colleague Dr. Bryon Adinoff wrote the following:

"Dr. Amen claims that numerous psychiatric illnesses can be diagnosed and treatments prescribed based on resting single photon emission computerized tomography (SPECT) images. Dr. Leuchter correctly points out the absence of empirical data to support the claims of Dr. Amen. Several years ago, following conversations with Dr. Amen on how to address such concerns, the Brain Imaging Council of the Society of Nuclear Medicine offered Dr. Amen the opportunity to submit his analyses of a blinded set of SPECT scans (to have been prepared by the Brain Imaging Council) to determine how effective his technique is at correctly diagnosing subjects. Although this proposed study could have provided support for his approach, the offer was declined. Nevertheless, for more than two decades, Dr. Amen has persisted in using scientifically unfounded claims to diagnose and treat patients (over 45,000 by his own count).

"There are several dangers to patients that can accrue from this approach: 1) patients (including children) are administered a radioactive isotope without sound clinical rationale; 2) patients pursue treatments contingent upon an interpretation of a SPECT image that lacks empirical support; and 3) based on a presumed diagnosis provided by Dr. Amen's clinics, patients are guided toward treatment that may detract them from clinically sound treatments.

"Just as serious is the danger to our field. It is likely that, within the next decade, Dr. Amen's claims will be realized in that psychiatrists will enjoy the ability to diagnose and prescribe treatments based, in part, upon neuroimaging findings. Unfortunately, if previously led astray by unsupported claims, patients and their doctors may be less inclined to utilize scientifically proven approaches once these are shown in the peer-reviewed literature to be effective.

"It is therefore incumbent upon all of us to monitor and regulate our field. We encourage physicians to remain vigilant of unproven approaches practiced by our peers and to immediately report these trespasses to their state medical boards."

Traumatic Brain Injury: Progress

A new study reveals that individuals with traumatic brain injury (TBI) have significantly more difficulty with gist reasoning than traditional cognitive tests. Using a unique cognitive assessment developed by researchers at the Center for BrainHealth at The University of Texas at Dallas, findings published Friday in the Journal of Clinical and Experimental Neuropsychology indicate that an individual's ability to "get the gist or extract the essence of a message" after a TBI more strongly predicts his or her ability to effectively hold a job or maintain a household than previously revealed by traditional cognitive tests alone. The study also further validates the Center for BrainHealth's gist reasoning assessment as an informative tool capable of estimating a broad range of daily life skills.
"Gist reasoning characterizes a meaningful, complex cognitive capacity. Assessing how well one understands and expresses big ideas from information they are exposed, commonly known as an ability to "get the gist", is window into real life functionality. I do not know of any other paper and pencil test that can tell us both," explained Asha Vas, Ph.D., research scientist at the Center for BrainHealth and lead study author. "Although performance on traditional cognitive tests is informative, widely-used measures do not paint the full picture. Adults with TBI often fare average or above on these structured measures. All too often, adults with brain injury have been told that they ought to be fine; in reality, they are not doing and thinking like they used to prior to the injury and struggle managing everyday life responsibilities years after the injury. Gist reasoning could be a sensitive tool to connect some of those dots as to why they are having trouble with real-life functionality despite falling into the range of "normal" on other cognitive tests." For more details and the longer article, click here.

Aging Brain? Not So Bad...

From Harvard Health Publications at Harvard Medical School comes some exciting news about the aging brain.

At middle age, the brain begins to draw on more of its capacity for improved judgment and decision making.
If you forget a name or two, take longer to finish the crossword, or find it hard to manage two tasks at once, you’re not on the road to dementia.
What you’re experiencing is your brain changing the way it works as you get older. And in many ways it’s actually working better. Studies have shown that older people have better judgment, are better at making rational decisions, and are better able to screen out negativity than their juniors are.
Although it may take you a little longer to get to the solution, you’re probably better at inductive and spatial reasoning at middle age than you were in your youth.


The brain changes as we get older, and in some ways it works better as we get older.



How is it possible for older people to function better even as their brains slow? “The brain begins to compensate by using more of itself,” explains Dr. Bruce Yankner, professor of genetics and co-director of the Paul F. Glenn Laboratories for the Biological Mechanisms of Aging at Harvard Medical School. He notes that MRIs taken of a teenager working through a problem show a lot of activity on one side of the prefrontal cortex, the region we use for conscious reasoning. In middle age, the other side of the brain begins to pitch in a little. In seniors, both sides of the brain share the task equally. The cooperative effort has a payoff. “Several studies suggest that seniors who can activate both sides of the brain actually do better on tasks, while those who can’t do worse,” Dr. Yankner says.

If you’ve found that it’s a little harder to carry on a conversation while searching your bag for your keys, MRI studies offer some clues. They show that in younger people, the area of the brain used to do a task goes dark immediately once the task is completed, while in older people it takes longer to shut down. As a result, it’s harder for the older brain to take on several tasks, because not only do you need to use more of the brain for any single task, but the brain also has a harder time letting go of a task. So even after you fish out your keys, you may have trouble getting back into the conversation.
What about the moments when you find yourself driving down the street without any recollection of having passed the last few blocks? Or the times you’ve locked the car door with your keys in the ignition? On those occasions your brain may have slipped into the default mode, which controls processes like remembering and daydreaming that are not required for a directed task. Imaging studies show that interconnected regions of the brain dubbed the “default network” grow more active with age, indicating that as we age we spend more time daydreaming.

THE GOOD NEWS ABOUT "THE MORE MATURE" BRAIN

At The Center for BrainHealth, as at Harvard, we are discovering that the more mature brain actually has advantages over its younger counterpart. These findings came as a surprise to many people, who were accustomed to seeing “senior moments”—groping for the right word or taking longer to articulate your thoughts—as a sign that the brain was on the skids. Yet even in professions where youth is valued, testing has shown that maturity has advantages.

For example, in a study of air-traffic controllers and airline pilots, those between ages 50 and 69 took longer than those under 50 to master new equipment, but once they had, they made fewer mistakes using it. (Keep this in mind when you’re trying to conquer a new computer program or adapt to a new car!) The mastery that comes with maturity is due to changes in your glands as well as your brain. Declining levels of testosterone—even in women—result in better impulse control. The end of the hormonal roller coaster of menopause may also contribute to emotional stability. After midlife, people are less likely to have emotional issues like mood swings and neuroses that interfere with cognitive function.

Most importantly, the wealth of knowledge from decades of learning and life experience enables you to better assess new situations. At midlife, most people are more adept at making financial decisions and getting to the heart of issues than they were when they were younger.

In most people, these abilities improve with age:

Inductive reasoning. Older people are less likely to rush to judgment and more likely to reach the right conclusion based on the information. This is an enormous help in everyday problem solving, from planning the most efficient way to do your errands to managing your staff at work.

Verbal abilities. In middle age, you continue to expand your vocabulary and hone your ability to express yourself.

Spatial reasoning. Remember those quizzes that require you to identify an object that has been turned around? You are likely to score better on them in your 50s and 60s than you did in your teens. And you may be better at some aspects of driving, too, because you are better able to assess the distance between your car and other objects on the road.

Basic math. You may be better at splitting the check and figuring the tip when you’re lunching with friends, simply because you’ve been doing it for so many years.

Accentuating the positive. The amygdala, the area of the brain that consolidates emotion and memory, is less responsive to negatively charged situations in older people than in younger ones, which may explain why studies have shown that people over 60 tend to brood less.

Attaining contentment. Years ago, researchers were surprised to find that people seem to be more satisfied with their lives as they age, despite the losses that accumulate with passing years. This is probably because they tend to minimize the negative, accept their limitations and use their experience to compensate for them, and set reasonable goals for the future. Dr. Yankner notes that this trait may be innate, because it is prevalent even in the United States and other Western nations, which tend to value youth over age.

Network Adequacy: Not Adequate

Finding a good psychiatrist is a challenge, but as it turns out it may even be hard to see a mediocre or poor psychiatrist. This is particularly true for individuals who have both psychiatric problems (like depression) along with alcohol, substance abuse, or other addictions.

Deceptive insurance company practices
According to Mark Moran, writing in the April 3, 2015 issue of Psychiatric News, access to psychiatry appears to be an area in which many health plans are offering deceptive products. This problem has been studied for many years in Maryland, near the nation's capital, where access to care has long been a troubled business. Previous studies done over the last 25 years by MHAMD and other organizations found there were long delays for individuals to access psychiatric care. In 1988, MHAMD published, “Study of Mental Health Coverage Provided by Maryland HMOs.”
This study sought to provide a comprehensive picture of the impact of HMOs on access to mental health care. The anecdotes from mental health professionals in 1988 illustrated the long wait times their patients faced when trying to secure an appointment with a psychiatrist. As a follow-up, in 2002, the Mental Health Coalition of Maryland conducted a survey of mental health professionals to ascertain how the managed care system affected an individual’s ability to access mental health care.


Psychiatrists dropping our of private insurance networks
Many respondents reported dropping out of private insurance networks, resulting in more consumers having to pay out of pocket for mental health care. In 2007, the Maryland Psychological Association published a white paper titled, “Access to Care in the State of Maryland.” Their survey found that 44% of mental health professionals listed in the managed care networks were unreachable, and that the average wait time for an appointment with a psychiatrist was 25 days.
In the same April 2015 article, attorney Colleen Coyle, general counsel for the American Psychiatric Association, said that "in many instances health plans advertise provider networks that appear to offer users of behavioral health services a wide range of option for access to care, but in reality those networks may be much "thinner" than consumers are led to believe.

Insurance false advertising is fraud
"In my view, that is fraud," Coyle said. The insurer is promoting a provider list that it knows is not reflective of the access to care that patients will really have. I don't think it's innocent at all."
She goes on to say that insurance plans are constantly looking at their providers and and claims "because that's how they target which providers to audit and whether they are going to challenge the claim."
John McIntyre, M.D., a past president of the American Medical Association, said: "Many insurers, in an attempt to hold down costs, employ very narrow or shallow networks that are inadequate to provide necessary medical care. But patients don't know that when they sign up."

The detailed report from The Maryland Mental Health Association is available online here.

Best Therapists = Best Outcomes (by far)

All psychotherapists and all psychiatrists are not the same. In the April 2015 issue of The Carlat Psychiatry Report, Dr. Scott Miller discussed the importance of the therapeutic relationship. “The best predictor of treatment outcome in mental health services is not the specific technique, but rather the provider of those services. In psychotherapy, for example, who provides the treatment is between five and nine times more important than what particular treatment approach is provided.” The discussion is amplified in: Wampold BE, Imel ZE. The Great Psychotherapy Debate, second edition. New York: Routledge; 2015. PsychCentral editor Therese Borchard comments on the qualities of good psychiatrists here.

Treatment: Know What to Ask


SEEKING TREATMENT: KNOW WHAT TO ASK

My goal in helping people includes educating them about what questions to ask.
Finding the right treatment for a person’s specific needs is critical. And finding the right treatment is not easy. Drug and alcohol addiction treatment is not “one size fits all.”

Treatment outcomes depend upon:
  • the extent and nature of the person’s problems;
    • the appropriateness of treatment;
  • the competence and skill of clinical staff;
    • the availability of additional services; and
    • the quality of interaction between the person and the treatment providers.


Family and friends play important roles in motivating people with drug problems to enter and remain in treatment. However, trying to identify the right treatment programs for a loved one can be a difficult process.

The National Institute on Drug Abuse (NIDA) has sound advice about the five questions to ask when searching for a treatment program:

1. Does the program use treatments backed by scientific evidence?
In the internet era, answering this question has become increasingly difficult. Many programs offer flashy "treatments" that are not scientific at all, despite claims made on beautiful web pages. According to Thomas McLellen, professor of psychiatry at the University of Pennsylvania, 90% of patients who enter addiction treatment programs don’t receive evidence-based treatment. Many current programs actually reject scientific evidence. For example, they prohibit the use of addiction medications, even though they’ve been shown to be more effective treating some addictions (specifically, the range of opiates like Oxycontin to heroin) than anything else. My concern is a bit different from Dr. McLellan's view (for example, he is not friendly toward 12 Step work). My major concern is that there are dozens of quack therapies, ranging from nutritional "cures" to "new age" approaches, to potentially harmful "trauma therapy."

A great website is not a guarantee that the advertised program is any good at all. Many programs today, using clever marketing, take advantage of opposition to Alcoholics Anonymous and 12 Step Programs by advertising that says, "We are NOT a 12 Step Program!" What these programs fail to do, in almost every example, is to state clearly what they actually do in their approach. Many other websites—and I have reviewed hundreds of them—claim to offer "evidence based treatment," when in fact the program is not evidence based at all. The average person has no idea whether or not claims of scientific evidence are true. Above all, beware of "testimonials" and celebrity endorsements. In selecting a treatment program, you have to use at least as much good judgment as you would use if you were buying a new car or having heart surgery.

Effective alcoholism and addiction treatments can include cognitive behavioral therapy, medications, or, ideally, the combination of both.

Key elements include:
• addressing a patient’s motivation to change;
• providing incentives to stop drinking or using drugs;
• building skills to resist alcohol/drug use;
• replacing addiction related activities with constructive and rewarding activities;
• improving problem-solving skills; and
• building better personal relationships.

Any and every good addiction treatment program will include competent assessment by a qualified addiction psychiatrist. Some programs will team an addiction medicine doctor with a well-qualified clinical psychologist, and that can work well. The point is that everything begins with getting the right assessment. Medications are an important part of treatment for many patients, especially when combined with counseling and other behavioral therapies. Different types of medications may be useful at different stages of treatment: to stop alcohol and drug abuse, to stay in treatment, and to avoid relapse.

2. Does the program tailor treatment to the needs of each patient?
No single treatment is right for everyone. The best treatment addresses a person’s various needs, not just his or her alcohol and drug abuse. Matching treatment settings, programs, and services to a person’s unique problems and level of need is key to his or her ultimate success in returning to a productive life. It is important for the treatment approach to be broad in scope, taking into account a person’s age, gender, ethnicity, and culture. The severity of addiction and previous efforts to stop using drugs can also influence a treatment approach.
The best programs provide a combination of therapies and other services to meet a patient’s needs. In addition to addiction treatment, a patient may require other medical services, family therapy, parenting support, job training, and social and legal services.
Finally, because addictive disorders and other mental disorders often occur together, a person with one of these conditions should be assessed for the other. And when these problems co-occur, treatment should address both (or all conditions), including use of medications, as appropriate.
Medical detoxification is a necessary first step in the treatment of certain addictions, but by itself does little to change long-term drug use.

3. Does the program adapt treatment as the patient’s needs change?
Individual treatment and service plans must be assessed and modified as needed to meet changing needs.
A person in treatment may require varying combinations of services during its course, including ongoing assessment. For instance, the program should build in drug monitoring so the treatment plan can be adjusted if relapse occurs. For most people, a continuing care approach provides the best results, with treatment level adapted to a person’s changing needs. A patient’s needs for support services, such as day care or transportation, should also be met during treatment.

4. Is the duration of treatment sufficient?
Remaining in treatment for the right period of time is critical. Appropriate time in treatment depends on the type and degree of a person’s problems and needs. People argue about this point all the time, and I don't have the patience or space on this blog to cite the references, but research tells us that most addicted people need at least three months in treatment to really reduce or stop their drug use and that longer treatment times result in better outcomes. The best programs will measure progress and suggest plans for maintaining recovery. Recovery from drug addiction is a long-term process that often requires several episodes of treatment and ongoing support from family or community. If you have read this far and are starving for the references, contact me.
Relapse does not mean treatment failure. The chronic nature of addiction means that relapsing to drug abuse is not only possible, but likely, similar to what happens with other chronic medical illnesses—such as diabetes, hypertension, and asthma—that have both physical and behavioral components. And like these illnesses, addiction also requires continual evaluation and treatment modification if necessary. A relapse to drug use indicates a need to re-instate or adjust treatment strategy; it does not mean treatment has failed.

5. How do 12-step or similar recovery programs fit into drug addiction treatment?
Self-help groups can complement and extend the effects of professional treatment. The most well-known programs are Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA), all of which are based on the 12-step model. This group therapy model draws on the social support offered by peer discussion to help promote and sustain drug-free lifestyles.
Most drug addiction treatment programs encourage patients to participate in supportive therapy during and after formal treatment. These groups offer an added layer of community-level social support to help people in recovery with abstinence and other healthy lifestyle goals.

To order NIDA materials, please go to: http://drugpubs.drugabuse.gov.

The Brain: A Good Introduction

One of my favorite journals, New Scientist, has an excellent introduction to the brain and how it works.

The brain is the most complex organ in the human body. It produces our every thought, action, memory, feeling and experience of the world. This jelly-like mass of tissue, weighing in at around 1.4 kilograms, contains a staggering one hundred billion nerve cells, or neurons.

The complexity of the connectivity between these cells is mind-boggling. Each neuron can make contact with thousands or even tens of thousands of others, via tiny structures called synapses. Our brains form a million new connections for every second of our lives. The pattern and strength of the connections is constantly changing and no two brains are alike.

It is in these changing connections that memories are stored, habits learned and personalities shaped, by reinforcing certain patterns of brain activity, and losing others. To read the article, click here.

Those Danged Cognitive Distortions

Lately I've been discussing CBT, or cognitive behavioral therapy, with a number of people, and the topic of cognitive distortions has come up several times. For convenience, I'm posting here the list of the common thinking patterns that generate distress and reduce psychological well being. In Alcoholics Anonymous, for example, this sort of problem is called "stinkin' thinkin'." See the links page for recommended sites on CBT and many other topics.

1. ALL-OR-NOTHING THINKING: You see things in black-and-white categories. If performance falls short of perfect, you see yourself or others as total failures.
2. OVERGENERALIZATION: You see a single negative event as a never-ending pattern of defeat. Phrases like "You always …" or "You never …" exemplify overgeneralization.
3. MENTAL FILTER: You pick out a single negative detail and obsess on it so that your vision of all reality becomes darkened, like the drop of ink that discolors an entire glass of water.
4. DISQUALIFYING THE POSITIVE: You reject positive experiences by insisting they "don't count" for some reason or other. In this way you can maintain a negative belief that is contradicted by your everyday experiences. Often this manifests as making excuses when somebody pays you a compliment.
5. JUMPING TO CONCLUSIONS: You make a negative interpretation even though there are no definite facts that convincingly support your conclusion often a "wait and see" attitude is called for in these situations.
MIND READING: You arbitrarily conclude (usually by personalizing their behavior) that someone is reacting negatively to you, and you don't bother to check this out.
THE FORTUNE TELLER ERROR: You often anticipate that things will turn out badly, and you feel convinced that your prediction is an already-established fact.
6. MAGNIFICATION (CATASTROPHIZING) OR MINIMIZATION: You exaggerate the importance of things (such as your achievements or someone else's goof up), or you inappropriately shrink things until they appear tiny (your own character defects or other people's acceptable behavior). This is also called the "binocular trick."
7. EMOTIONAL REASONING: You allow your negative emotions to color how you see the world with an "I feel it, therefore it must be true."
8. SHOULD STATEMENTS: You try to motivate yourself or others with should and shouldn't, as if needing be whipped and punished before you could be expected anything. "Musts" and "oughts" are also offenders. The emotional consequences are guilt. When you
direct should statements toward others, you feel anger, frustration, and resentment as do they!
9. LABELING AND MISLABELING: This is an extreme form of overgeneralization. Instead of describing your error, you attach a negative label to yourself. "I'm a loser." When someone else's behavior rubs you the wrong way, you attach a negative label to him "He's a dumb jerk!" Mislabeling involves describing an event with language that is highly colored and
emotionally loaded, and generally not factually descriptive.
10. PERSONALIZATION: You see yourself as the cause of some negative external event, which in fact you were not primarily responsible for.

My generation of psychiatrists was the first to break with the old-fashioned, unscientific model known as Freudian psychoanalysis—the stereotype of the patient lying on the couch for years and being "analyzed" by the shrink. For some reason, our generation just didn't see this as very helpful or useful. Psychoanalysis in its pure form means 4-5 visits a week to the psychoanalyst, and the typical course of therapy is measured in years! There were no outcome studies proving the effectiveness of this approach. We really wanted something that would produce results, and an approach that the average person could afford.

Dr. Ben Martin at PsychCentral describes the new, scientific talk therapy this way: Cognitive behavioral therapy (also known by its abbreviation, CBT) is a short-term, goal-oriented psychotherapy treatment that takes a hands-on, practical approach to problem-solving. Its goal is to change patterns of thinking or behavior that are behind people’s difficulties, and so change the way they feel. It is used to help treat a wide range of issues in a person’s life, from sleeping difficulties or relationship problems, to drug and alcohol abuse or anxiety and depression. CBT works by changing people’s attitudes and their behavior by focusing on the thoughts, images, beliefs and attitudes that we hold (our cognitive processes) and how this relates to the way we behave, as a way of dealing with emotional problems.

An important advantage of cognitive behavioral therapy is that it tends to be short, taking four to seven months for most emotional problems. Clients attend one session per week, each session lasting approximately 50 minutes. During this time, the client and therapist are working together to understand what the problems are and to develop a new strategy for tackling them. CBT introduces them to a set of principles that they can apply whenever they need to, and which will stand them in good stead throughout their lives.

Cognitive behavioral therapy can be thought of as a combination of psychotherapy and behavioral therapy. Psychotherapy emphasizes the importance of the personal meaning we place on things and how thinking patterns begin in childhood. Behavioral therapy pays close attention to the relationship between our problems, our behavior and our thoughts.

SMART Training for Teens

The Center for BrainHealth has created an exciting opportunity for Teens this summer – Teen SMART Camp!
Teen SMART Camp is a great chance for your children or grandchildren to boost their frontal lobe functioning and gain important strategies for learning.
For questions and registration, please contact Lindsay Gehan at Lindsay.Gehan@utdallas.edu or 972.883.3310

Over the last six years, BrainHealth researchers have trained more than 27,000 students in SMART through research grants. Results have shown significant changes in frontal lobe regions responsible for higher order thinking and problem solving after only 10 hours of training. SMART has shown substantial improvements in academic performance in those who have participated to date.
SMART is a series of seven cognitive strategies that can be applied to any learning context. As students’ progress through these steps, they learn to discard unsuccessful and superficial learning styles and to adopt a more robust, focused, and deeper-level strategic learning approach. Upon completion of the SMART training, students can apply the methodology to any subject and have been shown scientifically to do so over an extended period of time with success.
This summer’s teens will begin SMART Camp by receiving comprehensive strategy instruction, teaching them to use their brains more efficiently to improve learning. SMART campers employ their new strategies in a variety of fun learning activities involving academic content as well as personally-relevant materials such as their favorite song lyrics, television shows, magazine articles, or movies, emphasizing organizational and motivational skills. The training is designed to help the teens apply their newly learned strategies to everyday situations. Each camper works on an individual and a group project over the course of the camp to practice planning, goal setting and time management.
The brain is primed for higher order reasoning beginning in adolescence. As a result, this SMART program is offered for students who will enter the 7th through 12th grade in Fall 2015.
SMART Camp has a maximum enrollment of 20 students and are filled on a first-come, first serve basis. The full payment amount is due before the camp begins.
Schedule:
June 22-26th 2015 – The day will start promptly at 9:00 am and conclude at 3:00 pm.
SMART Camp takes place over one week at the Center for BrainHealth.
Please contact Lindsay Gehan at Lindsay.Gehan@utdallas.edu or 972-883-3310 for more information

Science on Will and Willpower - Part II

Although he is not known for work in the addictions, Roy F. Baumeister, Ph.D., a social psychologist at Florida State University, writes and does research on willpower, one of the most important issues in alcoholism, drug addiction, and other dependencies. In Willpower: Rediscovering the Greatest Human Strength, makes the case that willpower is a limited resource subject to being used up. In simple terms, we get up in the morning with a certain amount of gas in the tank, and by the end of the day we can be running on empty.

An excellent video of one of Roy's lectures is on my media page.

We try to control ourselves in all sorts of ways: eating right, exercising, avoiding drugs and alcohol, studying more, working harder, spending less. Baumeister says that the practical significance of all this is enormous. He says: "Most of the problems that plague modern individuals in our society — addiction, overeating, crime, domestic violence, sexually transmitted diseases, prejudice, debt, unwanted pregnancy, educational failure, underperformance at school and work, lack of savings, failure to exercise — have some degree of self control failure as a central aspect."

Baumeister goes on to say that two main traits that seem to produce an immensely broad range of benefits: intelligence and self-control. However, psychology has not found much one can do to produce lasting increases in intelligence. On the other hand, self-control can be strengthened, and the study of self-control is a rare and powerful opportunity for psychology to make a palpable and highly beneficial difference in the lives of ordinary people.

Image of Roy Baumeister

For example, in his research he has found that people perform relatively poorly on tests of self-control when they have engaged in a previous, seemingly unrelated act of self-control: "For instance, in a study in my lab, we invited some students to eat fresh-baked chocolate-chip cookies, and asked others to resist the cookies and munch on radishes instead. Then we gave them impossible geometry puzzles to solve. The students who ate the cookies worked on the puzzles for 20 minutes, on average. But the students who had resisted the tempting cookies gave up after an average of eight minutes."

"Such studies suggest," he continues, "that some willpower was used up by the first task, leaving less for the second. The pattern is opposite to what one would expect based on priming or activating a response mode. So we began to think that some kind of limited resource is at work: It gets depleted as people perform various acts of self-control. Over time, we have begun to link this resource to the folk notion of willpower."

Making decisions seems to use up our willpower. After making decisions, people perform worse at self-control. Conversely, after exerting self-control, decision-making shifts toward simpler and easier processes. That can lead people to make poorer decisions, or to avoid making choices at all. Apparently, decision making depletes the same resource as self-control.

One of Baumeister's examples of willpower depletion: "A dieter may easily avoid a doughnut for breakfast, but after a long day of making difficult decisions at work, he has a much harder time resisting that piece of cake for dessert. Another example might be losing your temper. Normally, you refrain from responding negatively to unpleasant things your romantic partner says. But if one day you’re especially depleted — maybe you’re trying to meet a stressful work deadline — and the person says precisely the wrong thing, you erupt and say the words you would have stifled if your self-control strength was at full capacity. What do you call this process? My collaborators and I use the term “ego depletion” to refer to the state of depleted willpower. Initially, we called it “regulatory depletion” because the first findings focused purely on acts of self-regulation. When it emerged that the same resource was also used for decision-making, we wanted a broader term that would suggest some core aspect of the self was depleted. We borrowed the term “ego” from Freudian theory because Freud had spoken about the self as being partly composed of energy and of processes involving energy."

In his book, Baumeister explains that some people imagine that self-control or willpower is something you only use once in a while, such as when you are tempted to do something wrong. The opposite is true. Research indicates that the average person spends three to four hours a day resisting desires. Self-control is used for other things as well: controlling thoughts and emotions, regulating task performance and making decisions. Most people use their willpower many times a day, all day. And toward the end of the day, there is less gas in the tank.

We now know that people can improve their self-control even as adults. As with a muscle, it gets stronger from regular exercise. So engaging in some extra self-control activities for a couple weeks produces improvement in self-control, even on tasks that have no relation to the exercise activities. The exercises can be arbitrary, such as using your left hand instead of your right hand to open doors and brush your teeth. Or they can be meaningful, such as working to manage money better and save more. The important thing is to practice overriding habitual ways of doing things and exerting deliberate control over your actions. Over time, that practice improves self-control. As people deplete willpower, they became increasingly likely to give in to desires they might otherwise have resisted. This was true for all manner of desires: desires to sleep, to eat, to have sex, to play games, to spend money, to drink alcohol or smoke cigarettes.

One of the best features of Roy Baumeister's work, particularly his book on willpower, is that he is easy to read, accessible to those of us not trained in clinical research or adept at deciphering scientific papers.

Videos Added to My Site

Check out the Media Page for some of my favorite videos, including Jon Kabat-Zinn on mindfulness, Martin Seligman on positive psychology, David Tolin on pseudoscience, and a special appearance by my new friend, "The Monk Dude," who meditates while playing the guitar. Old 12-Steppers will surely enjoy Richard Rohr's talk, "Breathing Under Water."

Genetics, Weird Facts, & Placebos

There are times when the practice of medicine is the most fascinating possible kind of work. For example, consider the placebo effect.

A placebo is anything that seems to be a "real" medical treatment -- but isn't. It could be a pill, a shot, or some other type of "fake" treatment. What all placebos have in common is that they do not contain an active substance meant to affect health. Younger physicians won't remember this, but years ago it was considered okay for doctors to prescribe placebos. Surgeons fairly often would substitute saline (salt water) injections when they worried that patients were asking for too many narcotic shots after an operation. There was a preparation called Gevrabon that was essentially sherry wine with some vitamins added, and it could be given by prescription "for relaxation at bedtime." Over the years, for obvious reasons, experts in medical ethics began to question whether these practices—essentially deceiving patients, but with good intentions—were proper and permissible.

In addiction medicine, I've seen college students come into the emergency room looking drunk, only to discover (with lab verification) that the "drug" they had tried was simply a vitamin pill. Similar findings have emerged at The University of Texas Austin, where one of the research labs has a full-fledged bar (i.e. a saloon) set up to simulate the settings where college students drink. Click here to see the Sahara Bar in the Department of Psychology. Study subjects sometimes get tipsy even when their margarita or manhattan contains no alcohol at all.

In 1996, scientists assembled a group of students and told them that they were going to take part in a study of a new painkiller, called "trivaricaine". Trivaricaine was a brown lotion to be painted on the skin, and smelled like a medicine. But the students were not told that, in fact, trivaricaine contained only water, iodine, and thyme oil – none of which are painkilling medicines. It was a fake – or placebo – painkiller. Read an abstract of the study: Mechanisms of Placebo Pain Reduction. With each student, the trivaricaine was painted on one index finger, and the other left untreated. In turn, each index finger was squeezed in a vice. The students reported significantly less pain in the treated finger, even though trivaricaine was a fake.

In this example, expectation and belief produced real results. The students expected the "medicine" to kill pain: and, sure enough, they experienced less pain. This is the placebo effect.

Placebo medicine has even been shown to cause stomach ulcers to heal faster than they otherwise would. These amazing results show that the placebo effect is real, and powerful. They mean that fake or placebo treatments can cause real improvements in health conditions: improvements we can see with our own eyes. Experiencing the placebo effect is not the same as being "tricked", or being foolish. The effect can happen to everyone, however intelligent, and whether they know about the placebo effect or not.

An article in Harvard Magazine describes Harvard Professor Dr.Ted Kaptchuk’s first randomized clinical drug trial, where nearly a third of his 270 subjects complained of awful side effects. All the patients had joined the study hoping to alleviate severe arm pain: carpal tunnel, tendinitis, chronic pain in the elbow, shoulder, wrist. In one part of the study, half the subjects received pain-reducing pills; the others were offered acupuncture treatments. And in both cases, people began to call in, saying they couldn’t get out of bed. The pills were making them sluggish, the needles caused swelling and redness; some patients’ pain ballooned to nightmarish levels. “The side effects were simply amazing,” Kaptchuk explains; curiously, they were exactly what patients had been warned their treatment might produce. But even more astounding, most of the other patients reported real relief, and those who received acupuncture felt even better than those on the anti-pain pill. These were exceptional findings: no one had ever proven that acupuncture worked better than painkillers. But Kaptchuk’s study didn’t prove it, either. The pills his team had given patients were actually made of cornstarch; the “acupuncture” needles were retractable shams that never pierced the skin. The study wasn’t aimed at comparing two treatments. It was designed to compare two fakes.

Dr. Kaptchuk and his colleagues have found that placebo treatments—interventions with no active drug ingredients—can stimulate real physiological responses, from changes in heart rate and blood pressure to chemical activity in the brain, in cases involving pain, depression, anxiety, fatigue, and even some symptoms of Parkinson’s. His work was also featured in a New Yorker article, "The Power of Nothing," that can be found here.

Here are four fascinating (and weird) facts about placebos and the placebo effect:

1. It doesn't have to be a secret. Some believe that a placebo can only work if the recipient is unaware they are taking one. But there's evidence that people with irritable bowel syndrome who knowingly receive a placebo do better than those who are left untreated.

2. It works better if it's expensive. The pain-killing power of a placebo pill is greater among people who are told they are taking a full-price version, compared to those told that the pill is on sale for a discounted price.

3. It's not just us, animals can get it too. A 2012 study found that between 30 and 40 per cent of rats experienced pain relief when their morphine injections were swapped for inactive saline solution.

4. It has an evil twin. The nocebo effect makes people undergoing treatment more likely to suffer from side-effects if they are warned about them by their doctor.

For the full New Scientist journal article on the subject, click here.

Slowly, over the past decade, researchers have begun to tease out the strands of the placebo response. The findings, while difficult to translate into medicine, have been compelling. In most cases, the larger the pill, the stronger the placebo effect. Two pills are better than one, and brand-name pills trump generics. Capsules are generally more effective than tablets, and injections produce a more pronounced effect than either. There is even evidence to suggest that the color of medicine influences the way one responds to it: colored pills are more likely to relieve pain than white pills; blue pills help people sleep better than red pills; and green capsules are the best bet when it comes to anxiety medication.

Mindfulness Based Relapse Prevention

Dr. Sarah Bowen has published a study on mindfulness and relapse prevention in JAMA Psychiatry, a specialty journal of the American Medical Association. According to Bowen, substance abuse is another example of that too-human automatic drive to move toward pleasure and away from pain—one that affects an estimated 24 million Americans, according to the National Survey on Drug Use and Health.

Traditional treatment for substance abuse often focuses on avoiding or controlling triggers that result in negative emotion or craving. While research has shown that this approach can help, substance abuse relapse remains a problem: about half of those who seek treatment are using again within a year.

Bowen has spent much of her career studying another approach: mindfulness, which involves cultivating moment-to-moment, nonjudgmental awareness of thoughts, feelings, and surroundings. She and her colleagues have developed a program called Mindfulness-Based Relapse Prevention (MBRP), which combines practices like sitting meditation with standard relapse prevention skills, such as identifying events that trigger relapse. Rather than fighting or avoiding the difficult states of mind that arise when withdrawing from a substance, this combination tries to help participants to name and tolerate craving and negative emotion.

But how do mindfulness-based approaches compare to traditional substance abuse treatments? And do mindfulness-based treatments work for everyone? Researchers like Bowen are beginning to answer these questions.

Here is the key to the success of the program: MBRP helps people to relate differently to their thoughts, and use tools to disengage from automatic, addictive behaviors.

The JAMA Psychiatry article describes how effective the Mindfulness-Based Relapse Prevention program is in comparison to a standard relapse-prevention program as well as a conventional 12-step program. Six months following the intervention, the mindfulness-based program and the standard relapse-prevention program were both more successful at reducing relapse than the 12-step program. One year later, the mindfulness-based program proved better than the other two in reducing drinking and drug use.

Bowen says that when people cultivate mindfulness, they’re developing a tool to become aware of that inclination to want only pleasurable things and escape uncomfortable things. Mindfulness also helps people learn to relate to discomfort differently. When an uncomfortable feeling like a craving or anxiety arises, people like Sophia are able to recognize their discomfort, and observe it with presence and compassion, instead of automatically reaching for a drug to make it go away. Bowen says that awareness of our experience and the ability to relate to our experience with compassion gives us more freedom to choose how we respond to discomfort, rather than defaulting to automatic behaviors.

More research is needed to determine why MBRP might be more successful than other programs in reducing substance abuse relapse, but Bowen speculates that MBRP holds an advantage because mindfulness is a tool that can be applied to all aspects of one’s life.

Standard relapse-prevention programs teach tools specific to struggles with substance abuse—for instance, how to deal with cravings or how to say no when someone offers you drugs. A year after completing the program, a person may have a very different set of challenges that the relapse-prevention program did not equip them to deal with.
But because mindfulness is a tool that can be used in every part of a person’s life, practicing moment-to-moment awareness could continue to be an effective coping tool.

James Davis and his colleagues at Duke University are investigating mindfulness training as a way to help people quit smoking. Davis speculates that mindfulness is likely an effective tool in helping people with addiction because it’s a single, simple skill that a person can practice multiple times throughout their day, every day, regardless of the life challenges that arise. With so much opportunity for practice—rather than, say, only practicing when someone offers them a cigarette—people can learn that skill deeply.

Their intervention results showed a significant difference in smoking cessation for people who completed the intervention, as compared to people who were given nicotine patches and counseling from the Tobacco Quit Line.

Both Bowen and Davis emphasize that mindfulness is not a panacea; it doesn’t always work for everyone.

Dr. Zev Schuman-Olivier and his colleagues at the Massachusetts General Hospital Center for Addiction Medicine suggest that the type of therapy a person responds to may have something to do with their disposition. People who had the tendency to treat thoughts and behaviors with non-judgment and acceptance before the intervention began were more likely to be successful in reducing smoking following the mindfulness training. They write that if a person already has the skill to treat the self with non-judgment and acceptance, learning mindfulness practices likely comes easier to them than someone who has not previously practiced this skill.

Ultimately, the type of therapy that works best for a given person will likely capitalize on their pre-disposed strengths.Of course, as Bowen and Davis both note, the skills of mindfulness can be taught to everyone. But Schuman-Olivier’s finding suggests that people who are not oriented toward mindfulness may need a more vigorous or lengthy intervention, in order to more thoroughly learn mindfulness skills. It may be the case that people with less disposition toward mindfulness would fare better with a different therapy.

Another predictor of success in mindfulness-based treatment could be a person’s motivation to engage in the therapy. In Davis’ study, the people that started the intervention with the highest level of nicotine addiction were the most successful in reducing smoking by the end of the treatment. Davis said that this seemingly counterintuitive result likely reflects their motivation to quit; the people that were the most addicted had, at that point, tried everything, and were willing to try their hardest to make this therapy work. Meanwhile, people that were less addicted saw their addiction as less of a problem. They reasoned, “If this doesn’t work, I’ll be ok—something else will work, eventually.” As a result, they were likely less motivated to quit, and less engaged in the therapy.

Being Mindful and Positive

The two practices that I've found most valuable over the past twenty years come from the new research in mindfulness and in positive psychology.

Mindfulness is natural, but we often overlook the importance of living in the present moment. There is not much new to learn; it's more about being aware of what is happening, who we are, and how to practice. We already have the capacity to be present, and it doesn’t require us to change who we are. You will hear me describe, in our conversations, topics like attention, awareness, empathy, compassion, being in the zone, situational awareness, presence, flow, contemplation, and many more. Being mindful has the power to change how we approach ourselves, our work, our relationships, and our communities. Mindfulness practice should be part of everyone's toolbox in the process of recovery from any mental or emotional setback. On my links page I have listed some useful resources on the subject.

Positive psychology began to emerge in the late 1980's through the research of my colleague Dr. Martin Seligman. If you have attended my talks on the positive psychology of addiction recovery, you've heard me describe "PERMA," the five dimensions of life where positive psychology produces meaningful results. Seligman outlines the categories in his book, Authentic Happiness. The acronym for the five elements of Seligman’s well-being theory is PERMA (Positive Emotions, Engagement, Relationships, Meaning and purpose, and Accomplishments).


PERMA image of the five domaines of positive psychology



What people in addiction recovery notice, usually right away, is the strong similarity between the findings of positive psychology research and the guiding principles of twelve step recovery.

Positive emotions include a wide range of feelings, not just happiness and joy. Included are emotions like excitement, satisfaction, pride and awe, amongst others. These emotions are frequently seen as connected to positive outcomes, such as longer life and healthier social relationships.

Engagement refers to involvement in activities that draws and builds upon one’s interests. Mihaly Csikszentmihalyi explains true engagement as flow, a feeling of intensity that leads to a sense of ecstasy and clarity. The task being done needs to call upon higher skill and be a bit difficult and challenging yet still possible. Engagement involves passion for and concentration on the task at hand and is assessed subjectively as to whether the person engaged was completely absorbed, losing self-consciousness.

Relationships are all important in fueling positive emotions, whether they are work-related, familial, romantic, or platonic. We receive, share, and spread positivity to others through relationships. They are important in not only in bad times, but good times as well. In fact, relationships can be strengthened by reacting to one another positively. It is typical that most positive things take place in the presence of other people.

Meaning is also known as purpose, and prompts the question of “Why?” Discovering and figuring out a clear “why” puts everything into context from work to relationships to other parts of life. Finding meaning is learning that there is something greater than you. Despite potential challenges, working with meaning drives people to continue striving for a desirable goal. The three criteria are that it 1) contributes to well-being, 2) is pursued for its own sake, and 3) is measured independently of the other elements of PERMA.

Accomplishments are the pursuit of success and mastery. Unlike the other parts of PERMA, they are sometimes pursued even when it does not result in positive emotions, meaning, or relationships. Accomplishment can activate the other elements of PERMA, such as pride under positive emotion.Accomplishments can be individual or community based, fun or work based.

The five domains are valuable to consider when "the program isn't working," because taking personal inventory usually comes down to looking at what's going on inside these categories. The five elements were sifted out of research on thousands of individuals who were interviewed on the broad topic of happiness.

Change Your Brain

And now…a word or two about good science and having a healthy brain. We offer a range of programs at the Brain Performance Institute to help people of all ages and conditions improve and extend peak brain performance throughout their lives. By evaluating brain fitness and applying proven brain-training methods, the Brain Performance Institute will train individuals to think smarter and exploit their greatest natural resources — their brains.

BRAINHEALTH PHYSICALS
A unique cognitive assessment that measures cognitive reserve in pivotal areas of higher-order mental functioning, all of which rely on robust frontal lobe function. It is just as essential to measure and monitor brain fitness as it is to measure and monitor physical fitness. Get a benchmark of your brain’s health.

HIGH PERFORMANCE BRAIN TRAINING
The high performance brain training program, Strategic Memory Advanced Reasoning Training (SMART®Winking, was developed by Center for BrainHealth cognitive neuroscientists and is based on more than 25 years of scientific study. The training program targets improvement in the frontal lobe of the brain and is based on cognitive neuroscience principles of how to build strategic thinking, advanced reasoning and innovative problem-solving skills. SMART sessions include personalized training materials and integrated practice sessions.

I joined the staff at The Center for BrainHealth and BPI after extensive contact with the scientists and clinicians there. Over a period of months I found myself returning at least once or twice weekly to attend a lecture, to discuss research, or to interact with my friends on The Warrior Team, a powerful resource for veterans. I remember the day in November 2014 when I spoke with Dr. Sandra Chapman, the CEO, and she asked me whether I was enjoying my visits. "Are you kidding me?" I said, "I want to be more than a visitor—I want to work here!" Needless to say, I was both honored and extremely delighted when, early in 2015, I got the call and the invitation to be Senior Medical Advisor for CBH and BPI.

Brain Scams: Don't Buy the MRI

Neuroimaging, or the use of functional magnetic resonance imaging to study the brain, is a powerful research tool. At The Center for Brain Health our scientists are doing amazing work in unraveling what goes on in the human brain, and imaging studies are essential to their research. However, fMRI studies do not enable us to diagnose or treat psychiatric disorders more effectively. There is quite a gap between the research lab and the clinic. Nonetheless, entrepreneurs have started marketing brain scans to consumers, and some doctors are making claims not supported by the science. These claims have been widely criticized and condemned, but the average consumer is easily duped. My distinguished colleague Daniel Carlat, M.D. wrote a brilliant article which you can find here in Wired magazine. There is also extensive discussion of the subject on Quackwatch, as well as on the Science Based Medicine Blog.

Dr. Carlat writes: "My journey through the land of functional neuroimaging has helped me to understand how spectacularly meaningless these images are likely to be. Most neuromarketers are using these scans as a way of sprinkling glitter over their products, so that customers will be persuaded that the pictures are giving them a deeper understanding of their mind. In fact, imaging technologies are still in their infancy. And while overenthusiastic practitioners may try to leapfrog over the science, real progress, which will take decades, will be made by patient and methodical researchers, not by entrepreneurs looking to make a buck."

If a person has a brain tumor, a brain aneurysm, or a stroke, then brain imaging can be helpful. However, brain imaging makes no difference (and makes no sense) in the treatment of problems like depression, anxiety, ADD/ADHD, alcoholism, addictions, or other commonly seen psychiatric disorders.

Brain imaging is very expensive, and the brain is exposed to radiation during a scan. This is an unnecessary risk, and a very expensive procedure, for anyone with a psychiatric disorder.

Beliefs Shape Our Reality

This month's issue of New Scientist includes a thought-provoking article on beliefs and our view of reality.

Surprisingly large numbers of people also hold beliefs that a psychiatrist would class as delusional. In 2011, psychologist Peter Halligan at Cardiff University assessed how common such beliefs were in the UK (see below for the top 10 delusions). He found that more than 90 per cent of people held at least one, to some extent. They included the belief that a celebrity is secretly in love with you, that you are not in control of some of your actions, and that people say or do things that contain special messages for you (Psychopathology, vol 44, p 106).
None of Halligan's subjects were troubled by their strange beliefs. Nonetheless, the fact that they are so common suggests that the "feeling of rightness" that accompanies belief is not always a reliable guide to reality.

The Top 10 Delusions

1. Your body, or part of your body, is misshapen or ugly 46.4%
2. You are not in control of some of your actions 44.3%
3. You are an exceptionally gifted person that others do not recognise 40.5%
4. Certain places are duplicated, i.e. are in two different locations at the same time 38.7%
5. People say or do things that contain special messages for you 38.5%
6. Certain people are out to harm or discredit you 33.8%
7. Your thoughts are not fully under your control 33.6%
8. There is another person who looks and acts like you 32.7%
9. Some people are duplicated, i.e. are in two places at the same time 26.2%
10. People you know disguise themselves as others to manipulate or influence you 24.9%

One of the most interesting things about belief is that it varies enormously from person to person, especially on issues that really matter such as politics and religion. According to research by Gerard Saucier of the University of Oregon, these myriad differences can be boiled down to five basic "dimensions" (Journal of Personality and Social Psychology, vol 104, p 921). At their core, he says, these concern what we consider to be worthy sources of value and goodness in life, whether it be a concept, an object, a supernatural being or a historical person. Your belief system is the aggregate of your position on each of these five dimensions, which are independent of each other.

1. Traditional religiousness: level of belief in mainstream theological systems such as Christianity and Islam
2. Subjective spirituality: level of belief in non-material phenomena such as spirits, astrology and the paranormal
3. Unmitigated self-interest: belief in the idea that hedonism is a source of value and goodness in life
4. Communal rationalism: belief in the importance of common institutions and the exercise of reason
5. Inequality aversion: level of tolerance of inequality in society, a proxy of the traditional left-right political split

To read the full article, click here.

Changing the Brain

Current neuroscience reveals that both psychotherapy and psychiatric medications produce positive changes in the brain. Research at UCLA demonstrates that people who suffered from depression had abnormally high activity in the prefrontal cortex.  Psychotherapy patients who improved show more nearly normal brain activity in this hyperactive region. For obsessive-compulsive disorder, OCD, cognitive behavior therapy (CBT) was associated with a decrease in the hyperactivity of the caudate nucleus, and the effect was most evident in people who had a good response to CBT.  In other words, the better the therapy seemed to work, the more the brain activity changed.
People with chronic fatigue syndrome (CFS) tend to have a decrease in a type of brain tissue called grey matter in the prefrontal cortex of the brain.  OCD researchers in the Netherlands provided 16 sessions of CBT, and found significant increases in gray matter volume in the prefrontal cortex.  This seems to suggest that the CFS patients were able to “recover” some gray matter volume after CBT.

The bottom line: Although medication and psychotherapy appear to work their magic in difference places, the results are positive for both. The mechanism of action remains unclear, but studies also show that the combination of psychotherapy and the right medication (getting it right is very important!) is an excellent approach for many individuals. As the brain changes, we see the production of new proteins, which change our brains through neuroplasticity.   In selecting a treatment strategy, sometimes medication works best, sometimes psychotherapy is the best option, and sometimes it’s a combination of the two. 

What Is a Disease?

During the course of my career, addiction treatment professionals (with a few notable exceptions) have consistently advocated on behalf of “the disease model.” As a professor, I have often asked seminar students to explain to me why they believe addiction is a disease. The results are sometimes surprising, not only because these future physicians seem puzzled, but also because they have a difficult time defining the word disease.

The ancient Greek academies had differing views of disease. Hippocrates emphasized the sick individual with his particular kind of misery. Others saw disease as a specific pathological process, evidenced by a visible sign such as a tumor, wound, or physical symptom. To this day, the definition of disease remains controversial. The AMA Council on Science and Public Health recently addressed the question, “Is obesity a disease?” The Council’s response: “Without a single, clear, authoritative, and widely accepted definition of disease, it is difficult to determine conclusively whether or not obesity is a medical disease state.”

This is also true for the vast majority of psychiatric disorders, particularly the addictions. The individual’s degree of suffering and incapacity—or distress and dysfunction—defines a state of disease. Although we now have some clues about the causes of mental disorders, and neuroimaging studies are making great strides, the American Psychiatric Association takes this position:

“The exact causes of mental disorders are unknown, but an explosive growth of research has brought us closer to the answers. We can say that certain inherited dispositions interact with triggering environmental factors. Poverty and stress are well-known to be bad for your health—this is true for mental health and physical health. In fact, the distinction between “mental” illness and “physical” illness can be misleading. Like physical illnesses, mental disorders can have a biological nature. Many physical illnesses can also have a strong emotional component.”

The National Alliance on Mental Illness (NAMI) seems to agree: “A mental illness is a condition that impacts a person's thinking, feeling or mood may affect and his or her ability to relate to others and function on a daily basis. Each person will have different experiences, even people with the same diagnosis. Recovery, including meaningful roles in social life, school and work, is possible, especially when you start treatment early and play a strong role in your own recovery process. A mental health condition isn’t the result of one event. Research suggests multiple, interlinking causes. Genetics, environment and lifestyle combine to influence whether someone develops a mental health condition. A stressful job or home life makes some people more susceptible, as do traumatic life events like being the victim of a crime. Biochemical processes and circuits as well as basic brain structure may play a role too.”

These questions highlight the importance of seeing the suffering person as more than a diagnosis or a label. This is the message I emphasize in my presentation, “Four Sides to Every Story,” available on request. Diagnosis is helpful, because we know that certain treatments are effective for certain diseases. For example, some fevers are caused by infection, and if we kill the offending bug we can cure the disease. Other fevers are caused by inflammation—as in rheumatoid arthritis or drug reactions—and if we calm the inflammation we can ease the fever.

At the same time, the psychiatrist should see much more than a label or a diagnosis (what the patient has in terms of the disease model). The psychiatrist—or any mental health professional—should also take the other three perspectives into account: who the person is, what the person does, and what the person has encountered. Using all four perspectives, the disease model can be valuable. It’s just not the whole story.

Do 12-Step Programs Work?

Do mutual help organizations like Alcoholics Anonymous really work? Last year, The Carlat Report on Addiction Treatment reviewed the research on AA and reported positive findings. I've summarized that report and included the references here. AA and other 12 Step programs provide many of the elements found in formal treatment. More importantly, the recovering fellowship creates a framework for support over the long term, helping individuals stay sober longer, have fewer drinking days, and have shorter periods of relapse. Twelve Step Facilitation (TSF) has been found as effective as cognitive behavioral therapy in addressing alcohol-related issues.

Since the 1930's when Bill W. and Dr. Bob started Alcoholics Anonymous (AA) the fellowship has grown to over two million members. Meeting in rented rooms, school halls, hospitals, and the storied church basement, AA and similar 12-step organizations (eg, Narcotics Anonymous [NA]) remain the most commonly sought sources of help for substance-related problems in the United States (Substance Abuse and Mental Health Services Administration. Results from the 2007 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies; 2008).

Research has shown that attending AA, either alone or during and following professional treatment, enhances outcomes. One naturalistic study, for example, followed 466 previously untreated individuals with problem drinking for eight years. Participants self-selected into one of four groups: no treatment, AA alone, formal treatment alone, and formal treatment plus AA. Those who received some sort of help—AA, formal treatment, or both—had higher rates of abstinence at all time points. At eight years, 26% of patients in the no treatment group were abstinent from alcohol compared to 49% who received AA alone, 46% who received formal treatment alone, and 58% who received the combination of treatment plus AA (Timko C et al, J Stud Alcohol 2000;61(4):529–540).

A systematic Cochrane review of the best scientific studies on AA and TSF found that they were as effective as any of the interventions to which they were compared for some factors, such as retention in treatment, but found that no studies unequivocally proved AA and TSF were superior to other treatments (Ferri M et al, Cochrane Database Syst Rev 2006;(3):CD005032).

Other studies have found a linear dose-response relationship between AA attendance and favorable drinking outcomes (Kaskutas LA, J Addict Dis 2009;28(2):145–157). Attending one meeting per week, on average, appears to be the minimum threshold to realize benefit and increasing meeting frequency is associated with progressively greater rates of abstinence. In addition, research has shown that women engage with AA as much as men, become more involved with the 12 Steps, and derive similar benefit. In 1990, the Institute of Medicine called for more research on how AA works. Since then, research has revealed that AA aids recovery through multiple mechanisms, many of which are also activated by professional behavioral treatments (Kelly J et al, Addict Res Theory 2009:17(3):236–259).

Most consistently and strongly, AA appears to work by helping people make positive changes in their social networks (eg, by dropping heavy drinkers/drug users and increasing abstainers/low risk drinkers), and by enhancing coping skills and self-efficacy for abstinence when encountering high-risk social situations (see for example, Kelly JF et al, Drug Alcohol Depend 2011;114(2–3):119–126).

Among more severely addicted people, AA also appears to work by enhancing spiritual practices, reducing depression, and increasing individuals’ confidence in their ability to cope with negative emotion (Kelly JF et al, Addiction 2012;107(2)289–299). Thus, AA appears to work through diverse mechanisms and may work differently for different people. Stated another way: individuals may use AA differently, depending on their unique needs and challenges.

Research has shown that involvement in 12-step work can reduce the need for more costly treatments while simultaneously improving outcomes. A large multicenter study of over 1,700 patients found those treated in professional 12-step treatment went on to participate in community-based AA and NA meetings at a higher rate than those from professional cognitive behavioral therapy (CBT) programs, who relied more heavily on professional services. This translated into a two-year savings of over $8,000 per patient among 12-step treated patients, without compromising outcomes. In fact, those treated in the 12-step treatment programs had one-third higher rates of abstinence across follow-up (Humphreys K & Moos R, Clin Exp Res 2001;25(5):711–716; Humphreys & Moos, Alcohol Clin Exp Res 2007;31(1):64–68).

Project MATCH was a large randomized trial comparing three individually-delivered psychosocial treatments for alcohol use disorder—TSF, CBT, and Motivational Enhancement Therapy (MET)—that was funded by NIAAA. It included 1,726 patients from nine clinical sites across the US (Project Match Research Group, J Stud Alcohol 1997;58(1):7–29). TSF was found to be as effective as the more empirically supported CBT and MET interventions at reducing the quantity and frequency of alcohol use post-treatment and at one- and three-year follow-ups. Moreover, TSF was superior to CBT and MET at increasing rates of continuous abstinence, such that 24 percent of the outpatients in the TSF condition were continuously abstinent at one year after treatment, compared with 15 percent and 14 percent in CBT and MET, respectively (Tonigan JS et al,Participation and involvement in Alcoholics Anonymous. In: Babor TF & Del Boca FK, eds. Treatment Matching in Alcoholism. New York: Cambridge University Press;2003:184–204).

Abstinence rates at three years continued to favor TSF, with 36 percet reporting complete abstinence, compared with 24 percent in CBT, and 27 percent in MET (Cooney N et al. Clinical and scientific implications of Project MATCH. In: Babor TF & Del Boca FK, eds. Treatment Matching in Alcoholism. New York: Cambridge University Press; 2003:222–237).

In light of findings from several such RCTs that demonstrated the efficacy of TSF, this therapy was added to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Practices and Programs (NREPP) in 2008.

The overwhelming majority of research has been conducted on AA. More research is needed on other MHOs, such as SMART Recovery, LifeRing, Celebrate Recovery, Women for Sobriety, Moderation Management, and others, so that more objective evidence is gathered on secular, religious, and non-abstinence-based AA alternatives (see the article "Alternatives to 12-Step Recovery" for more on these groups).

Identifying the Effective Psychiatrist

This essay on my philosophy began as a statement, but gradually the essay morphed into a series of questions. As I began to write, I started to feel as though I should have written this many years ago. I began to experience a deep sense of gratitude toward the many individuals who have taught me with such patience, kindness, and wisdom for so many years. I realized that my philosophy should reflect my desire to be a good psychiatrist. This blog post also appears on my philosophy page.

Practicing medicine is a privilege granted to very few individuals, and I am indeed fortunate. Within the field of medicine, working in psychiatry requires more than an understanding of anatomy and organ systems, because psychiatry is about the mind, the brain, the self, and human experience.
Like any other professional, I believe in high ethical standards, sound knowledge of my field, and the importance of practicing wisely and compassionately. Beyond the obvious nostrums and philosophical cliches, however, I want to be one of the good psychiatrists. As I thought about this lately, I began to wonder: how does one identify and recognize a really good psychiatrist? What makes a good psychiatrist? If I made a list of the most important aspects of a psychiatrist’s professional philosophy, what would that look like?

In 2006 an article was published in the Journal of Affective Disorders showing that good psychiatrists prescribing placebos (sugar pills) had better results than poor psychiatrists prescribing actual medication. Over 120 patients were divided into two groups, one group that received sugar pills and another group that received full strength psychiatric medication for depression. At the same time, each psychiatrist was rated on a number personal qualities: verbal fluency, interpersonal perception, expressiveness, warmth, acceptance, empathy, and the ability to focus on the other person. When results were analyzed, the psychiatrists strong in these personal qualities had the best results, even when the “medication” they prescribed was not medication at all.

The effective psychiatrists were fluent, clear, and expressive in speaking, and they had an accurate feel for their patients. Rather than being distant and aloof, the good psychiatrists were warm, friendly, and accepting. The good psychiatrists empathized well, spent more time with their patients, were more thoughtful in their strategies, and formed strong therapeutic partnerships. The point of the study was that having a good psychiatrist makes a difference in recovery.

Although medication can be extremely helpful in psychiatric care, treatment is not all about medication. The combination of the right medication, the right psychotherapy, and the right psychiatrist is the key to success.

Research has shown for generations that some clinicians consistently produce better results than others, regardless of the type of psychotherapy or theoretical orientation of the practitioner. Hundreds of studies have shown that the differences between types of psychotherapy is very small, but the psychiatrist providing the psychotherapy is critically important.

Over the past fifteen years, extensive research has given us a solid body of evidence about the qualities and actions of effective psychiatrists. Based on the psychotherapy research of Dr. Bruce Wampold of The University of Wisconsin, I have formulated here an inventory that provides the basis for judging whether a psychiatrist is likely to be effective.

  • Effective psychiatrists demonstrate a sophisticated set of interpersonal skills, including verbal fluency, perceptiveness of others, emotional intelligence, expressiveness, warmth, and acceptance. Given these gifts, the most effective psychiatrists are those who are first excellent physicians, well trained in medicine, competent to practice at the highest levels.

  • Effective psychiatrists are inquisitive, questioning, and seeking new knowledge constantly. They embrace science while at the same time possessing the humility to know how little we really know.

  • Patients of effective psychiatrists feel understood, trust the psychiatrist, and believe the psychiatrist can help. The psychiatrist creates these conditions in the first moments in both speech and action. In the initial contacts, patients are very sensitive to cues of acceptance, understanding, and expertise. Although these conditions are necessary throughout therapy, they are most critical in the initial interaction to ensure engagement in the therapeutic process.

  • Effective psychiatrists are able to form a working alliance with a broad range of patients. The working alliance involves the therapeutic bond, but also importantly agreement about the task of goals of therapy. The working alliance is described as collaborative, purposeful work on the part of the patient and the psychiatrist. The effective psychiatrist builds on the patient’s initial trust and belief to form this alliance and the alliance becomes solidly established early in therapy.

  • Effective psychiatrists provide an acceptable and practical explanation for the patient’s distress. The patient wants an explanation for his or her symptoms or problems. There are several considerations involved in providing the explanation. First, the explanation must be consistent with the healing practice. On the medical side, the explanation is biological, and in psychotherapy the explanation is psychological. Second, the explanation must be acceptable and compatible with the patient’s attitudes, values, culture, and worldview. Third, the explanation must provide a strategy by which the patient can overcome difficulties and solve life’s problems. These three factors together make for a strong therapeutic alliance.

  • The effective psychiatrist provides a treatment plan that is consistent with the explanation provided to the patient. Once the patient accepts the explanation, the treatment plan will make sense and patient compliance will be increased. The treatment plan must involve healthy actions—the effective psychiatrist promotes healing by replacing failed strategies with effective strategies. At the same time, strong defenses will replace weak defenses, and healthy practices will replace self-defeating behaviors.

  • The effective psychiatrist is influential, persuasive, and convincing. The psychiatrist presents the explanation and the treatment plan in a way that convinces the patient that the explanation is correct and that following through with the treatment will benefit the patient. This process leads to patient hopefulness, increased expectancy for mastery, and healthy actions. These characteristics are essential for forming a strong working alliance.

  • The effective psychiatrist is honest and authentic. Authenticity refers to communication to the patient that the psychiatrist truly wants to know how the patient is doing. The best psychiatrists tend not to use checklists, scales, and paper measures. Instead, they talk and listen openly and honestly.

  • The effective psychiatrist is flexible and will be patient if resistance to the treatment is apparent or the patient is slow to make progress. Although the effective psychiatrist is persuasive, persuasion can be a process that takes time. The good psychiatrist pays attention, takes in new information, test hypotheses about the patient, and is willing to be wrong. A good psychiatrist will seek second opinions, refer to other specialists, and even take calculated risks such as trying a new approach or a newly released medication.

  • The effective psychiatrist does not avoid difficult material in therapy. Doctor and patient must use such difficulties therapeutically. We all tend to avoid material that is difficult. The effective psychiatrist senses avoidance is taking place and does not collude to avoid the material. Instead, the psychiatrist will discuss the difficult material and address difficult problems. Sometimes conversations can be difficult, and at times the relationship between doctor and patient can be strained, but this is part of the work of therapy. The good psychiatrist can use skill, experience, and compassion to overcome these barriers to recovery.

  • The effective psychiatrist communicates hope and optimism. Sometimes this is easy to do, and sometimes it’s difficult. The working partnership must maintain hope and optimism in the face of chronic illness, relapses, lack of consistent progress, and many other difficulties. Effective psychiatrists acknowledge these issues and still communicate hope that the patient will achieve realistic goals in the long run. This communication is not blind faith or Pollyanna optimism, but rather a firm belief that together the psychiatrist and patient will work successfully. At the same time, effective psychiatrists mobilize patient strengths and resources to facilitate the patient’s ability to solve his or her own problems. The best doctors know that the patient, through his or her work, is responsible for therapeutic progress, creating a sense of mastery.

  • Effective psychiatrists are aware of the patient’s characteristics and context. This is a tall order with many categories: culture, race, ethnicity, spirituality, sexual orientation, age, physical health, motivation for change, and beyond. Furthermore, the effective psychiatrist is aware of how his own background, personality, and beliefs figure into the relationship.

  • The effective psychiatrist is aware of his or her own psychological process and does not inject his or her own material into the therapy process unless such actions are deliberate and therapeutic.

  • The effective psychiatrist is aware of the best research evidence related to the particular patient, in terms of treatment, problems, and social context. It is very important to understand the biological, social, and psychological basis of the patient’s problem.

  • The effective psychiatrist seeks always to improve, always to be a student. Hippocrates said, “The life so short, the craft so long to learn,” and truer words were never spoken.

  • Finally, the good psychiatrist must possess both humility and a sense of humor. We will never know enough, or be wise enough, to have all the answers. We cannot take ourselves too seriously, lest we become arrogant, prideful, and set ourselves apart from those who have graced us with the privilege of being socially sanctioned healers.

Development of skill in psychiatry involves intensive practice and unceasing professional growth. Patients are sometimes our best and most effective teachers. A few years ago I taught a seminar for third year students at the University of Texas Southwestern Medical School, “Psychiatric Nightmares, Disasters, and Catastrophes.” The entire content of the seminar consisted of mistakes I’d made, errors I had committed, and pitfalls that these students likely would encounter, sooner or later, in their medical careers.

I told the story of a patient with whom I’d had a terrible, angry argument, and how guilty I felt for years about my lack of composure—only to have the patient return, two years later, to ask me for a job at the hospital and tell me that she had been shaken into reality by our confrontation. I told them the story of the patient who overdosed and came to the ICU, and how I was baffled by the case—until I realized that the patient had diabetes, and was actually in a diabetic coma, not a drug-induced state.

I told them about the patient who came to the doorstep of my home on a Sunday afternoon, bearing in her arms her injured pet cat, hoping that I could help. I told them about an elderly man from New Orleans who was my patient in the middle of the night as Hurricane Katrina washed away his home.

And I told them about the time when I was called to the ER to examine a beautiful young woman, a Duke University cheerleader, who had bruised her shoulder. When I approached her to examine the injury, and she undid her gown and dropped it with a smile, I calmly reached into the pocket of my white coat for my stethoscope, only to realize that I then stuck my reflex hammer in my ear.

These encounters are the building blocks of the effective psychiatrist’s life. I’ve come to realize that most of the learning happens after we graduate. As Dr. Stead used to say at Duke, “Medical school is where you stay for four years until you’re old enough to become a doctor.”

Treatment Philosophy

My work includes general psychiatric problems like anxiety, depression, attention deficit disorder, substance abuse, family conflict, childhood behavior, stress, and other issues. Many people know me through my work as a specialist in the treatment of alcoholism and other addictions or chemical dependencies.

My approach to psychiatric practice reflects many years studying human nature and working to help people who are having a hard time in life. By the time most people see a psychiatrist, they are worried, or they are sad, or they are very confused about something I will just call “the problem,” or “the complaint.” Let me make some general comments about my approach, and then I will discuss my thinking on the use of medications.

People seek psychiatric help for a variety of problems, but everyone wants the same result: to feel better, to think more clearly, to rediscover satisfaction and happiness, and to regain a sense of self control and personal freedom. The problem may be related to mood, energy level, motivation, sleep, worry, relationships, anger, troubled behavior, obsessions, compulsions -- it’s a long list. People who drink too much, use drugs, or misuse prescription medication are often using these chemicals to find relief. Alcoholism and substance abuse are widespread in our culture.

Dealing with life is never easy.

Most persons first try to solve the problem or deal with the complaint on their own. Frustrated that things aren’t improving, they may seek advice from others. Sometimes a person hides the problem or lives in silence with the complaint. They may read a book, go to a support group, consult the internet, or try a new religious practice. We all have problems and complaints, and we all do the best we can to solve the dilemmas of life. When someone calls me about consultation, I almost always hear them say that they have a problem, they have tried to solve the problem, and they are looking for someone who knows how to help make things better.

One of the individuals consulting with me said, “I feel like I’m in a box, and the directions for getting out of the box are printed -- on the outside of the box.”

A successful airline pilot, a Vietnam combat veteran, said, “Doc, I’m out of altitude, airspeed, and ideas.”

Often the person seeking help has waited so long that demoralization has begun to set in, and they are beginning to lose hope. This doesn’t mean that the individual is suicidal or, in fact, any more unhappy than many of the people at the workplace or in the neighborhood. It means that they are resigned to always feeling this way, never feeling any better than this. Demoralization means a state of mind in which a person considers accepting fate, giving up, and abandoning the idea that things can get better.

Fear, anger, resentment, feeling constantly wounded, feeling overwhelmed, feeling unappreciated, feeling worthless -- all of these emotions are part of our lives. But when we feel negative all the time, or most of the time, most days, then we need help. There are very few emotional problems that defy intelligent therapy and reasonable efforts toward a solution.

When I meet someone for the first time in consultation, I have three major concerns. First, I want to get to know the person and hear about the problem are the complaint. My first question usually is simply, “How can I help?” or “What brings you to see me?” Second, I want to explore the individual’s point of view or understanding of the problem, including what solutions have been attempted. Third, I want to consider what we can do, working together, to improve the situation. I tend to focus more on results than on reasons. I’m not always sure about why things happen, but I am very focused on what we can do now. Sometimes I explain in detail how the brain works, and sometimes I discuss how life works. The process of recovery involves growth, change, and even personal transformation.

Research shows that psychotherapy can help, medication can help, and intelligent problem solving helps. Psychotherapy is not for everyone, and medication is not for everyone, but the vast majority of people who want help can find it. One of my favorite expressions is, “You have to do it yourself, but you can’t do it alone.”

Over the years I have developed a style that I call “sober conversation.” The word “sober” does not apply just to alcohol and addictions. To be sober is to be serious, to focus on what is most important, and to try to get it right. I believe in the importance of what we care about, and in this regard I have seriously studied the specific problem of human will. I call it “the problem of human will” because we are often confused about what we will ourselves to do, or not to do. When I work as a psychotherapist, I am most interested in what people care about, how their beliefs and assumptions about life have been formed, and where they feel stuck or at odds with themselves. Sometimes we have conflicting feelings about the same thing. For example, someone wants to take life in a certain direction, but he or she feels conflicted about it. Or someone tries to solve a problem, not realizing that it’s part of a bigger problem, or a different kind of problem. My definition of psychotherapy is that it is a form of personal consultation, focused on the situation of the client, with the goal of solving problems and feeling better.

Not everyone is cut out for in-depth or long-term conversation. Some people like to come for a few visits, and some like to keep going for weeks, or even months on a weekly basis. Some people prefer to come two or three times a week because they want to do the work and get on with whatever is next. Some people come for an hour, and some come for an afternoon.

Psychotherapy does take time, because the process is basically two people getting to know each other in the context of a specific purpose. Psychotherapy at its best is about taking life seriously, getting it right, and feeling the satisfaction that comes from clarity of thought, commitment to integrity, and comfort with the complexity of one’s own emotions and ideas. Some say that psychotherapy is a dying art, and this may be true. Psychiatrists today (and perhaps psychologists as well) do not receive the extensive training in psychotherapy that we did thirty years ago. Many psychiatrists and psychologists are not interested in psychotherapy. And many psychotherapists are not really very good or very well trained. Today there are thousands of people who call themselves “life coaches,” and anyone can hang out a shingle and call himself a “life coach.” There are several private organizations that offer “certifications,” but there are no license requirements, there is no government regulation, and no educational standard that is generally accepted. For these reasons, I think the concept makes sense, but in practice let the buyer beware -- caveat emptor!

Medications can be very helpful in treating some specific psychiatric problems. Today we have excellent medications for anxiety, depression, moodswings, insomnia, attention deficit disorder, and other conditions. Bipolar disorder, for example, is a devastating condition that can be very effectively managed with medication, restoring individuals to a life of normalcy and stability. I have absolutely no doubt about the value of psychiatric medications. I also believe that what is most important is getting the right diagnosis and the correct strategy for intervention and treatment. I see many people who have been misdiagnosed, and even mistreated, because they have not been well assessed. Assessment can take time, and I never jump to conclusions about diagnosis. After knowing someone for a few weeks, together we may decide that we see the condition in a different way.

Psychiatric medications are powerful, effective tools when used properly, but they also have side-effects, and they are expensive. Getting the right medication for the right diagnosis is extremely important. And there is an old saying from Hippocrates, creator of The Hippocratic Oath: “It is more important to know what sort of person has a disease than to know what sort of disease a person has.“

Thoughts and Reflections

My mission in life is to use my skills as a physician (M.D.) and psychotherapist to help people. As a psychiatrist, I serve individuals and families across a wide range of conditions and diagnoses. To read more about my professional credentials and to read my biographical sketch, click here. When I assembled this website five years ago, I didn't have a blog, and I didn't update very often. Recently I've decided to be a bit more spontaneous, adding thoughts and reflections here from time to time. This blog will reflect some of my continuing thinking, learning, and exploration.


Psychiatry as a medical specialty is a vast—and often uncharted—territory. The basic education of a psychiatrist is highly scientific and technical. The first two years of medical school are purely basic science: anatomy, physiology, biochemistry, microbiology, and so on. The last two years include brief exposure to psychiatry and psychology, but most of the time is devoted to medicine, surgery, ob-gyn, and pediatrics. Internship and residency years in psychiatry involve patient care, but the psychiatrist’s true education begins after graduation. As the venerable Dr. Eugene Stead used to tell us at Duke, “Medical school is where you stay until you’re old enough to learn how to be a doctor.” The education of the good psychiatrist is a process that lasts a lifetime.

Thanks for reading!