…and thanks for all the fish.

I’m heading out for a little while.

With the new year coming, I just wanted to spend a few pixels letting you all know I appreciate your attention to my ramblings and pontifications.

For those who’ve taken the time to express an interest, drop a comment or a like, or throw some dense solid object at the screen, thanks.

(And for the latter group, I hope that brickbat didn’t do too much damage to your electronics.)
Thanks, happy new year, and good luck. See you when I get back.

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The Way of the White Handkerchief.

My Dad’s Law of Psychiatry: The most important tool in your shop is a white handkerchief.

When I was an intern, I was pretty good at procedures. Which means I could stick needles in people and hit the right unseen person part (good) and not the wrong one (occasionally disastrous).

When you are a medical intern, this matters. The ability to get access to a large central vein or an artery can save someone from being  far up Excrement Creek with no means of propulsion.

This might be an odd point of pride for a psychiatrist, but I think the way I sank those central lines is much the same way I approach psychiatry.

You will occasionally hear people talk about how medicine is an art, not a science. This is utter crap. Medicine is neither an art nor a science, and frankly I think doctors just love to portray it as either because we sound far more highfalutin than what we are.

Medicine is  a craft.

We are trades(wo)men.

Science is concerned with developing knowledge through a rigorous system of doubt and observation. Medicine, in the sense of doing medicine, is not about making knowledge. It’s about using that knowledge to get a result.

Art is about getting a result too, but it’s an aesthetic one. Medicine is not about aesthetics.

A carpenter can make an absolutely beautiful joint. If it doesn’t hold, it’s still a failure. The fundamental aesthetic of the crafts(wo)man is in how simply, elegantly, and cleverly he can make something that works.

My father is a mechanic by trade, though he’s the sort of Southern post-Depression farm boy who knows how to do a little of everything. Most of the house where I grew up, he put together. He can fix damn near anything that rolls and a significant number of things that float.

He taught me his Law of Psychiatry, which really is a fundamental law of all trades, when he showed me how to rebuild a carburetor.

My Dad worked mostly on small engines, like lawn mowers. The fuel and air mixture is controlled by a device called a carburetor. Most of these look like a miniature Borg cube on the outside and the nest of an aluminum-eating termite on the interior. They use a set of diaphragms, springs, and valves to meter the flow of fuel into the air stream entering the engine.

On small engines, some of these bits are minuscule. One bit of grit, a drop of water, or a hardened seal that allows a little leakage can turn it into a paperweight. Which is why they often have to be cleaned and rebuilt.

When my father taught me how to do that, he pulled out the white handkerchief he carries everywhere and laid it on a bare area of the bench.

“This,” he announced, in that weighty I’m teaching you something so listen up kid tone, “is the most important tool you have.”

Into the center he placed the carburetor. As he disassembled it, he placed each part at progressively smaller distances from the carburetor body, until upon that white handkerchief sat a realized version of the schematic from a parts book, with the carburetor exploded yet the place of each piece in the whole obvious.

Because you saw how they came apart, you saw how they came together. The notch in the needle valve obviously fit that tab in the float, and the spring pressed in the opposite direction. So there, on that white handkerchief, three little chunks of metal turned into a poised equilibrium between buoyance, tension, and resistance.

After that, Dad replaced each of the old parts on the white handkerchief with the new ones, and put the whole thing together again with an almost musical rhythm.

In my memory, this is the place where the value of method crystallized. The pragmatics of the method are obvious – it keeps you from losing stuff and helps you remember what you did.

There’s more to it, though. Method, you see, is a means to understanding. Because we’re talking about craftsmanship here we are talking about understanding that works; the kind of knowledge that really is power. It’s the way you break something hopelessly complicated into pieces that can be managed, which lets you encompass all that hopeless complexity and do something useful in spite of it.

I remember in residency a meeting with a group of psychoanalysts who were to teach us psychotherapeutic technique. One of them, when discussing a particularly algorithmic form of psychotherapy, disparagingly compared it to “paint by numbers” while implying psychoanalysis was more akin to “van Gogh.”

See, the thing is: I’m not @#$%ing van Gogh. If I did paint-by-numbers, at least I’d come out with something recognizeable. If I tried being van Gogh, I’d have something only my relatives would hang on a wall, and that would be in the basement.

People aren’t canvases and the goal when you’re dealing with someone who’s suffering is not to use her to demonstrate your artistic psychotherapeutic genius to your artistic therapeutic genius pals. It’s to do something that works in a way that it keeps working. It is this emphasis on the literary over method that is my major gripe with analysis, and I think its ultimate downfall.

The methodical way leaves you with a working carburetor, repaired quickly, efficiently, and with a bare minimum of cursing. (In fairness, those little springs are %^~@#ers. They can fly like bullets and render themselves invisible instantly.) It ain’t Starry Night, but it will cut grass.

(I challenge anyone to produce a metaphor more mixed than that one.)

When I was an intern and opened the central line kit the first time, I instantly recognized the most important tool in the box. It was the spare sterile towel that wrapped the kit. It was blue paper, but I knew it for what it was. The White Handkerchief.

Upon that blue towel, I extracted every bit of that kit, lined up at increasing distance from my hand in order of need. Looking at that setup was like Satori, coming home, and a pulled pork sandwich all rolled into one.

That’s the aesthetic of the thing. The beauty of the system, that clean white surface like an inhaled breath waiting.

Yeah. I am a compulsive freak.

The White Handkerchief, of course, isn’t necessarily a thing. Sometimes it is that most wondrous and useful of medical tools, the 3×5 card. Sometimes it is the three seconds at the end of the interview when you take a breath, close your eyes, and all those pathways you’ve burned into your head over the last two decades spit out what they’ve been semiconsciously processing while you’ve been listening, lined up left to right: behaviors, reinforcers, alternate behaviors, new contingencies. Syndrome, course, response to prior treatment, next option.

Most of the time, though, it’s the few minutes before I sit down with a new patient. In my head I have a square of white cotton unfolding over a banged-up metal bench, between two thick hands on which small cuts and grease are so constant they are part of the flesh.

Then, I’m ready.

Thanks, Dad.

 

Redemption through irritation management

Dr. K’s Law: Use your irritation to help the patient.

When last we left our heroine and her interlocutor, Arpie had just provided a story that strained the principles of probability, thermodynamics, biochemistry, and behavioral science. She risked tearing a hole in the space time continuum to convince Dr. C. she was not using marijuana.

A question was raised toward the end, there; a question about the character of this Dr. C. person and his backing Arpie into a corner about her (admittedly, glaringly obvious) lie. Is he, perhaps, enjoying this a little too much? This cat-and-mouse, I’ve-got-you-my-pretty game he’s playing?

What if you knew that every minute poor Ms. Arpie is squirming, Dr. C is chewing nails, too?

Dr. K’s Law is named after one of my many mentors, a brilliant and all around loveable curmudgeon. The good Dr. K was known for:

  1. A scent reminiscent of burning cured leaves wafting from his non-smoking office. Strange, that.
  2. A picture from a certain era involving long hair and a Harley.
  3. A vocabulary that would make a $10 impolite-word-for-sex-worker blush.
  4. Being approximately 95th percentile in eff you.

I love that SOB, for the record.

In addition to the above, Dr. K was known for taking on some patients that most other docs would not touch with a very long and highly insulated pole. The severely personality disordered, the manipulative, the deceptive, the intolerably histrionic. He took absolutely no crap off them. He liked them. He thought they were fun. He got them better.

Now, how could one of the most no-s@#t people you could ever meet manage that feat? Because he is an absolute master of managing countertransference, you see.

A little technique here: “countertransference” is a historical word that harks back to psychoanalysis. Without getting too bogged down in (completely crazy and unsubstantiated) theory, “transference” is the patient’s reaction to the therapist, which is expected to echo relationships with important prior figures. In psychoanalysis, a lot of the technique involves the therapist “interpreting” the transference, pointing out how the therapy mirrors life, thereby helping the patient achieve insight so the patient can stop repeating these patterns.

Countertransference is the therapist’s complementary reaction to the patient. 

General therapeutic principle: Countertransference sucks.

Here is an example of the development and operation of countertransference:

Patient: Hello, Doctor. Thank you so much for your help last week.

Doctor: So you took my advice and had that conversation with Jenny?

Patient: After I thought about it, I decided I was making a mountain out of a molehill.

Doctor: So you didn’t discuss your sense that she’s been undercutting you?

Patient: No.

Doctor: I see. Well, how have you been doing?

Patient: OK. It’s just whenever I talk about my work, Jenny tells me to stop complaining. I feel like every aspect of my life is just miserable.

Doctor: Quietly contemplates risks and benefits of executing WWE style backhand slap upside patient’s head.

The doctor did not, in fact, execute a WWE style backhand slap upside the patient’s head. He did not consider it. Even for a moment. This is entirely fiction.

If he had done such a thing, that would be countertransference in a nutshell. One of the things that makes psychiatrists (and all other psychotherapists) different is that when we’re doing psychiatrism, we have to be looking three different directions.

The first is the everyday talking-to-someone level. Then there’s the inward eye, watching constantly what you’re feeling and thinking, looking for something fishy. Am I angry? Sad? Pitying? Is it more than it should be? That’s the countertransference. Last is the version of yourself that stands six feet to the left and watches. What is it about this interaction that is triggering that feeling? That’s the process, the secret dirty trick of all psychotherapists. After that last part, it is time to employ the Second Law.

In the best case scenario, the next few minutes go like this:

Doctor: When you first came to see me I asked what the trouble was, and you didn’t know, except that you had some sense that you were “stuck.” Since you couldn’t see any particular problem to address, I started offering you specific advice. Each week, I offer more advice, and you say you will try it, but so far not much has changed. To be frank, I’m  getting pretty frustrated. Yet still, despite the fact it clearly doesn’t work, I find myself telling you what to do.

I remember you said that Jenny constantly nagged you to do things, and she didn’t understand how hard it was for you. You said you kept trying to do what she wanted, but eventually just gave up and ‘shut down.’

When I look at what’s happening in therapy and what happened with her, I wonder if there may be some common pattern?

Patient, as heavenly shaft of light shines down upon him: O sage and clear-eyed doctor, now I see! I seldom directly deal with the obstacles in my life. When someone offers advice after I complain about my lack of progress, I resent her for making me feel guilty. Eventually she takes me for a passive-aggressive kvetch and explodes, thereafter executing a WWE style backhand slap upside my head. Eureka! My eyes are open! No doubt I will have difficulty overcoming my passive coping style, but at least I can communicate to people that I only need them to listen when I have a difficult time; and perhaps I can commit to using that listening time to come up with plans rather than simply complaining and resenting my partner for making suggestions I find frightening. Thank you, O healer of my soul!

That never happens, but oh it felt good to pretend for the few minutes it took me to write that. Actually, I’m going to pause and savor that for a couple more seconds. Pardon me while I glow.

To be completely fair, that does happen. What I just presented is the  “inspired by true events,” Lifetime network,  “Courageous story of a woman who escaped her baby-eating Satanist husband” version of the process. The way the real thing works is a lot more slowly.

Back to Arpie and Dr. C.

A thing you might not know, on account of your not paying attention when I didn’t tell you, is that this little encounter is the middle of a longer story. The beginning was some weeks ago, when Arpie brought someone into her house who was actively using drugs against the advice of everyone she knew, including her counselor and the good Dr. C. Not only is Arpie lying, she is lying to the people who care about her who are exactly the ones who told her not to get into this situation in the first place.

After heaven knows how many cycles of this, Arpie’s friends and family are long fed up with her. Let’s be frank here, Dr. C. is pretty fed up, too. So is her counselor, an otherwise superhumanly patient soul who’s been on the front lines watching this slow rolling train wreck for weeks and powerless to do anything about it. 

Dr. C. could just call her on this crap, and tell her straight out that she’s lying and he’s not going to reward such behavior by cutting her any slack. Satisfying, in its way. The psychotherapeutic equivalent of the WWE upside-the-head slap option. Except, you see, confrontation doesn’t work so well. Particularly for somebody who’s angry.

Why? Could be for a thousand reasons. The lie, like other strategies for dealing with a problem, has a function. Just ripping that crutch right out from under someone probably just leaves him flat on his tuchus , equally scared and frustrated but with no idea what to do about it. Which tends to mean he gets really mad at whoever dumped him on his tuchus and maybe just bails right out of treatment. At which point the Fundamental Law of Prognosis takes full effect.

(Attentive readers will note I just avoided unprofessional language such as a@@. I’m getting better!)

Alternately, Dr. C could just nod, smile sympathetically, and let nature take its course. Let her keep lying until she slams head first into reality. That will teach her.

Except it won’t. The goal is to stop the relapse in progress; not to let it take its course until she’s a bloody wreck and out of treatment to boot.

So calling her out doesn’t work, and doing nothing doesn’t work. Now what?

Dr. C. spent some time building this cognitive dissonance up. Is it because he’s an antagonistic #$@# and he’s miffed with her? Let’s be honest: YES. Countertransference is certainly a factor here. 

In his defense: It is, however, consciously managed countertransference.

Perhaps someone who has certain . . . difficult .  .  . personality traits and some hard earned (through the equivalent of a number of WWE-style-yadda-yadda from reality and the occasional friend, mentor, or wife) self-awareness may apply those characteristics to the present situation in some way that is beneficial to his patient.

For one thing, he is one stubborn @#%#@, and he doesn’t like letting one of his flock go without a fight. For another, he likes the underdogs. Perhaps he has some sympathy for those with certain ahem personality characteristics.

So maybe, just maybe, he used that rough streak and his own irritation to set up an endgame. Cognitive dissonance is the motivational equivalent of stored energy. It wants to discharge itself. While Arpie’s doing her level best to dodge the consequences of her behavior; this Dr. C. keeps just forcing her over and over to become more and more uncomfortable with how inconsistent what she’s doing is with the better self she’s been building. Even more diabolical, he hasn’t given her the least excuse to blame him for it.

Now, what can that endgame be?

Maybe saying something like:

Arpie, I have no crystal ball and I can’t read anybody’s mind. There are two possibilities, though. One is that you’ve been positive for marijuana for weeks on several pretty specific laboratory tests, and you’re not using. If that’s the case, then I am terribly sorry for what is about to happen to you. You’re going to lose this program.

The other is that you’re doing something that’s causing this. It wouldn’t be unusual if somebody was reluctant to talk about that. But that’s actually the better option. Because if that’s true, then you can do something different.

If this program matters to you, and there is anything at all you can do that will lead your tests to be negative, you should do that. We all care about you, and you’ve done really well here, and we would hate to lose you.

Every word is absolutely true, absolutely authentic, and passive-aggressive as all get-out. The lie is called without being called. There is nothing to manufacture anger from and blame the injustice of it all for what she’s doing. She’s stuck, faced only with a bunch of people who care for her and her own behavior, and that wrong feeling in her gut.

Arpie looked a little trapped and sputtered half-heartedly for a while. Then she looked lost, like all the fight was out of her. She walked out looking resigned.

What happened after that?

She pulled it out of the fire. Well, the one Arpie mostly is pulled it out.

It took a while for the testing to show up negative – weed takes a long time to wash out. Could be that she got an extra week or two once some doctor or other heard that she threw that guy out of the house. Could be.

The day came, though, when she tested negative and got back into that better life.

Hopefully, she never has to deal with that Dr. C guy again.

He can be . . . difficult.

He does mean well, though. Every once in a while, he probably even helps somebody out. Not every time. Let’s hope, for his sake and his flock’s, that it is enough.

Maybe there is enough redemption to go around.

Let’s hope.

 

…with both hands and a flashlight.

Dear my friends in the news media, repeat after me:

An infant cannot be born #$%#$% addicted to drugs.

I do not know what’s been going on lately, but I have seldom heard so much flat-out stupid, uninformed, backward reporting on the opioid epidemic as I have been hearing in the last couple of weeks. It’s been so widely distributed among different outlets that I’m not sure it’s even fair to single out any one particular corporation.

The first such noises I heard were about “fetal assault” laws. It boils down to threatening imprisonment for women who are pregnant while using illegal drugs if they don’t get treatment. The getting-into-treatment part I dig; however, interestingly enough, one often finds such States have a lot more room in jails than they do in treatment programs. Funny, that. Wouldn’t it be nice if the States had enough treatment slots to provide treatment on request and massively ramp up the drug court system, instead of all this retroactive stuff? I think so.

The media pointing out the ethical problems of this is fine with me. However, we got into a whole other realm when pregnancy outcomes started getting discussed. One was the neonatal abstinence syndrome – basically, opioid withdrawal in an infant. In some of these reports, reporters were constantly and unself-consciously referring to “infants born addicted to drugs,” including when talking about kids born to mothers who take methadone or buprenorphine.

There are several huge problems with this and I’m only going into a couple because I’ve already had too much coffee and I’m trying to maintain normotension. The first is this: Why are you not talking about cigarettes and alcohol?

To be fair, this is a problem with the media and with the legislatures. Illicit drugs are tremendously stigmatized and they do godawful amounts of damage, but let’s face it – the legal drugs probably cause the most public health harms. If your goal was seriously to impose consequences to prevent pre-natal injury to infants, you would hang a breathalyzer around every pregnant woman’s neck and lock up anyone who tested positive for nicotine while pregnant. In terms of long-term outcomes, “neonatal abstinence syndrome” is probably nothing much compared to fetal alcohol syndrome and all the stuff that smoking can do.

So that’s one. Here’s the second: the constant lumping of therapeutic drugs in with active addiction.

It happens several ways; one of them with the use of the word “clean.” As in:

She couldn’t tolerate the withdrawal, and her doctor told her that quitting cold turkey could be dangerous. So she went to a methadone program, hoping that it could serve as a bridge to getting clean.

Because, you know, nobody on methadone is really “clean.” Even if, for the last 5 years, she happens to be showing up to work at 8:00 every morning, leaving at 6:00, looking after her kids, abiding by the law, paying taxes, and generally being a productive human being. She is still “dirty.” Unlike that guy who just walked out of detox two days ago and refused to get into the treatment that would keep him from relapsing in the next two weeks. He’s “clean.” Right? Right.

I wonder how many reporters writing these stories spent the morning talking about who’s “clean” and who’s “dirty,” and then hoisted a couple at happy hour after work.

I get my knickers particularly twisted about this because this stigma kept coming up for the people in a program I worked in. They had to be careful in the Fellowships because even though some newbie might be nodding out in the back row with pupils the size of the period at the end of this sentence; if they talked about being on methadone, they were instantly “unclean.” It’s even more ridiculous out in the community, where being on either methadone or buprenorphine cuts you off from all kinds of resources. You can have treatment for your cravings and withdrawal, or you can have a roof over your head, but not both. Crazy.

The common thread to this craziness is a fundamental confusion.

Addiction is a behavioral disorder.

You cannot know how people are behaving based on what chemicals are in their blood. Go to a cancer ward and check out how much morphine and fentanyl are floating about. Now ask which of them should be locked up, or which are “dirty.”

This also is why you can’t be born addicted. No three-day-old is going to raid Daddy’s medicine cabinet or slip out to the corner to meet his boy to cop some pills.

It’s about how you act. There are situations in which taking opioid medications, like methadone and buprenorphine, helps people act better. It helps them stop using, stop getting infected with really nasty viruses, helps them turn into functional parents and citizens. As long as there is some implicit assumption that success only counts if you do it without medicines, and the highest goal for addiction treatment is to be medication free; we will be encouraging people to stop doing stuff that works. That is not the way we’re going to dig our way out of this hole.

I don’t know why these various media outlets feel they can file such reports with an obvious lack of expert guidance. Any good they do questioning the ethics and effectiveness of criminal justice based responses gets washed away when their next sentence stigmatizes some of the most effective treatments we’ve got, and further teaches potential patients that such treatments render them “unclean.” They are operating with exactly the same stigmatizing assumptions that lead these legislators to pass these laws.

Dear my friends in the media:

Find some actual addiction docs, talk to them. Take this seriously.

The truth is out there, but on your own, you’re not going to find it …

Stick to your knitting, please.

Not too long ago I had a look at this on what I am learning is the outlet of all medical knowledge in the blogosphere, KevinMD. I have another bone to pick with Kevin, M.D. later.

This one, however, is about a post that took as its jumping-off point a book by Allen Frances about the ins and outs of developing DSM-V.

So here’s where things started to go wrong:

It defines mental illness, and in the process also defines what is normal.

Is that what it does? Funny, I have never once consulted a DSM manual (to the extent that I do) to figure out if someone was normal.

Then, we round the bend with this one:

Objectivity is often mistaken for science and truth, but no line cleanly separates disease from normality. Both reside in the Gaussian curve.

No. No, they don’t. Not at all.

The author is a radiologist. I am wondering, when she looks at a chest radiograph, how she decides what percentile of pneumoniation the patient has. Is it 70th percentile, “borderline pneumonia?” 95th percentile, “severe pneumonia?” Where, on the Gaussian pneumonia curve, does one draw the line for “having pneumonia?”

I note the slippery word “disease.” Is what we mean by “disease” being in the 5th or 95th percentile on some Gaussian curve?

It’s not what I mean when I say that. When I have the flu, I’m not saying “I believe that I am currently in the 95th percentile of malaise, fever, rhinorrhea, and myalgias.” What I am thinking is

Well, what I’m thinking when I have the flu is mostly unprintable.

Disease, though, fundamentally, involves a qualitatively abnormal state, rather than a quantitatively abnormal one. Which is why so many of psychiatry’s conditions fit awkwardly there.

I really, really don’t want to get in the business of “What fools these mortals be” with non-psychiatrists. Because, most mortals are not fools and there are plenty of fools in psychiatry.

However, in the words of the not-exactly-immortal-but-with-remarkably-little-body-fat Henry Rollins, “Knowledge without mileage equals bulls–t.” When I hear someone talking about what I do, and I detect a distinct lack of mileage in their conceptualizations, I will listen. But expect a jaundiced eye.

I have a theory, and it is fundamental to the point I’m about to (try to) make. Always good to state your assumptions at the outset, yes?

From talking to lay folk, I think people appreciate that there are various propensities to negative human emotions and behaviors; sadness, anger, anxiety. That is, undoubtedly true. The variation in those emotions or behaviors is fundamental to current theories about personality.

Here’s where I think common assumptions diverge from reality: Psychiatry is about identifying people on the “bad end” of this distribution, and medicating or therapizing them to get them closer to the “good end.”

Mind you, I think in some cases that’s close to true. However, there are plenty of cases where it isn’t; and assuming that’s all there is to it leads to a lot of confusion.

When looking at someone with schizophrenia, I am not trying to assess what percentile on the auditory hallucinations Gaussian curve this patient is. There is no Gaussian curve for hearing the CIA agent who is monitoring your thoughts from across the street talking through your vents.

Then we have mania. Alzheimer’s Disease. Huntington’s Disease. Catatonia. Lead intoxication. Highly recurrent and chronic depression. OCD. Panic disorder.

It seems that every time there is any sort of disturbance in The Force around psychiatry, the media and the public erupt into a roil about how psychiatrists are pathologizing or medicalizing everything. This tends to center on the most ambiguous and fuzzy categories in psychiatry at the time, while ignoring how very little the most severe and clear cut diagnoses have really changed since, well, Hippocrates. Probably earlier.

Here are some things worth knowing:

  1. Nobody who actually uses the thing, including the people who write it, thinks the DSM is anything resembling a “Bible of Psychiatry.” If it were, it wouldn’t get changed around every two decades or so (thus creating the disturbance in the Force previously mentioned).
  2. Psychiatrists do not prowl the streets looking for people to medicalize and medicate. By and large, people come to us; and they typically do it because they are suffering. (Some are forced. They may be suffering too, but sometimes they’re just making other people suffer. That’s a different dynamic, and tricky.)
  3. A whole lot of people who come to see us are really just sick. Really. That’s it. They have major depression, just like their mother and grandfather; or they have manic-depressive illness or schizophrenia.
  4. When you have somebody in front of you who is suffering and asking you for help, you @#$#ing try to help, whether what causes that suffering fits into some neat category or not. In order to do that, you have to write something down for why you’re helping and (sadly, in many cases) the DSM is the lingua franca to do that.

From where I sit, the fundamental problems with the DSM fall into two areas: lump or split, and diseasifying in the name of reliability.

The lump or split problem has to do with the fact that the most disease-like entitities in psychiatry have funny variations. It may be that people with bipolar disorder with really frequent episodes need to be treated in a different way than people who have more intermittent episodes. Some people get psychotic during their episodes, others don’t. Should we have separate categories for these things, or not? Notice it’s not a question of whether such things happen. We know this is real, it’s just how we write it down. One place this has played out recently is in the substance use disorder categories, in which the “abuse” and “dependence” distinction finally has been dumped in favor of a severity specifier. There are those who will look at the fact that the “Substance Use Disorder” prevalence will increase and screech about overdiagnosis; and then there are those who will note that the overall picture really just looks like those who fell in the old “abuse”category now fall into the “mild SUD” category.

The diseasifying problem mainly has to do with things that don’t fit the disease mold so well, but that we can still help out with. Often we can help quite a lot. Things like personality disorders, addictions, and maybe some stuff like generalized anxiety disorder or ADHD. In these things, overlearned behaviors, or being at the wrong end of some Gaussian distribution(s), are what lead to the suffering. Of course, it could be in twenty more years we find some reasonably qualitative-looking pathophysiologic difference in these folks, and it turns out the disease model will work better.

Even so, it would be a lovely, lovely thing if somebody could say “This person is 95th percentile on Neuroticism and 2nd percentile on Agreeableness and the fear, anger, distrust, and hostility with which he approaches the world is limiting his life and causing all kinds of frustration and trouble for him.” However, the medical system (and the medical payment system) is built around the disease model, and for all the furor when something iffy gets talked about in disease terms, heaven help you if you want to help people like that and keep your shingle out, ’cause nobody is gonna pay unless it’s real,  by which I mean (sing along with me) a brain disease.

If people are really so concerned about medicalizing everything, here’s what I would suggest:

  1. Keep your eye on the most disease-like entities in psychiatry. When you get bent out of shape about how the prevalences in some other categories change, notice how little the prevalence of schizophrenia, bipolar disorder, major depression, panic disorder, OCD, etc. change. Then, breathe deeply and calm yourself. They’re not coming to drag all you normal folks in to a psychiatrist’s office and shove pills down your throat.
  2. With respect to the ones where the prevalence does change around, first ask how would I figure out what the right prevalence is if I were trying to do this? If you simply think any increase is a mistake, you have an implicit bias. Figure out what it is, and question it. (Same the other way.)
  3. If you would like to stop pharmaceutical companies from influencing diagnosis, stop the direct advertising and push for limitations on how they influence doctors. The place to start with the latter, by the bye, might well be with primary care physicians (including pediatricians).
  4. If you would like to stop stuff that isn’t particularly disease-like getting diseasified, push for a world where a professional can get paid to help someone who is suffering so long as a clinical entity can be reasonably defined and there is a treatment that can work. Then the everything-is-a-disease crowd don’t have a built-in advantage.
  5. If you really, really, really care about vague diagnostic entities, diseasifying stuff that doesn’t fit disease reasoning very well, and so forth; psychiatry may not be the only place to look. Look up the history of fibromyalgia, or think about obesity, diabetes, cardiovascular disease, smoking, and on and on. That line of reasoning has led me to think that psychiatry is mainly special in that we are earlier in our history and we know we are often missing the boat. Perhaps such humility, applied to the rest of medicine, might yield some interesting results.

Lyin’ Lies

Carroll’s 5th Law of Psychiatry: Anybody who says “I’ll be honest with you,” isn’t. Anybody who asks, “Why would I do that?” did that.

One thing I found hard to digest when I was starting out is that people lie to you. Well, not just people. Patients. People I’m trying to help.

I suspect I get lied to with the approximate frequency of a judge, but less than a cop. I have statistical evidence to back that up in the form of many anecdotes. I will share one with you now.

(At some point I will write a post about how anecdotes are stories of things that never happen. Ignore that, it only applies to other people’s anecdotes. Mine are entirely true, widely generalizable, and say something very important about the human condition. Promise.)

Once upon a time in Baltimore or its near environs there was a psychiatrist. He (or she – could have been anybody, really) was in a meeting where an absolutely real patient who is not at all abstracted from dozens of identical encounters was talking to him.

ARPWINAAAFDIE (Arpie for short): I am being treated horribly unfairly!

Dr. C. (not his real name, I’m sure): In what way?

Arpie: I keep getting put into all these groups. It’s just too much, I can’t get to all of them.

Dr. C. : Is there some reason for this?

Arpie: I keep coming up positive for weed! (“Coming up positive” means testing positive for a drug. Oddly enough, almost nobody ever says “I used.” One “comes up positive” as though there is a lottery for such things.)

Dr. C. : That can happen sometimes. There are false positives. So you have to go to some extra groups for a week?

Arpie: No!

Dr. C. : No?

Arpie: I’ve been in groups for six weeks!

Dr. C : For a single positive urine test?

Arpie: No. I’ve been positive for six weeks!

Dr. C. : And why do you think that is?

Arpie: I was around some people who were smoking. My cousin does it in the house all the time with his friends.

Dr. C. : I see. You ever have a problem with marijuana?

Arpie: Used to.

Dr. C. : I see. So you previously had a problem with marijuana, and you have been in a house with several people who are smoking constantly, and you have been positive on urine testing for weeks, but you have not been smoking?

Arpie: Right. I mean, I have been doing great in this program. It saved my life. Why would I do anything to jeopardize that?

And there it was. The “Why would I do that?” Notice she did not say “I did not do that.” In fact she never flat out denied it.

The practiced eye will also note that Dr. C. never said whether or not he believed her.

From this exchange, we can conclude one very, very important thing. Arpie is probably not a raging psychopath. We’ll get back to that.

Most people really, really suck at lying. The main reason people really, really suck at lying (and I have evidence to back this up in the form of expert opinion, because I am an expert) is that we are wired for consistency. Saying one thing and believing another produces an internal tension that psychologists give a catchy name, “cognitive dissonance.” People act to minimize this. One way people minimize this is they re-align their beliefs to fit what they say. As one student of mine once said, “You remember when you were a kid and you were acting sick to get out of school, and after a while, you started kinda feeling sick?” That sort of thing.

When lying, people often minimize dissonance by half-a%%ing it. They try to get away with saying something that is as little untrue as possible. They fudge details but leave the main story intact, they talk around the lie without ever flat-out lying. This, in terms of prevarication, is a terrible mistake. Because this almost always produces an internally inconsistent narrative.

You can get away with that if your listener doesn’t care much about the answer.

Compare and contrast:

Friend: “How are you?”

Depressed person who hasn’t smiled in a month: “Fine.”

Friend: “Did you hear about what happened at that picnic?”

and:

Doctor: “How are you?”

Depressed person: “Fine.”

Doctor: “OK, now that we’ve got that out of the way, how are you?”

Depressed person: Dissolves into tears.

In the first, the question is a social nicety and nobody particularly pays attention to the answer. In the second, when somebody notices the disconnect between what is seen and what is said, and asks for real; the truth comes out.

So, if your listener is paying attention and knows what she’s doing, you’re probably screwed. If she’s good at this, she’ll be calm and nonjudgmental, so you don’t have any excuse to act angry and throw up a smokescreen. She’ll watch how uncomfortable you are. She will never commit to either disbelief or belief. Either way would let you off the hook. She will never accuse you, nor give you an excuse to attack her and discharge all that pent up tension.

She’ll also be watching to see how hard you are working not to say something. That something will be the lie. She could toss out some not-quite-neutral comment about how she’s open to believing you, like how “false positives do happen. ” She might alternate that with pushing you right into a corner repeatedly, giving you a choice between telling the lie and making up some new detail, to increase the dissonance. I was taught by one of the great masters of this, who advocated the Columbo Technique – adopting a non-threatening, bemused manner from which you can endlessly ask about “just one more thing.”

Eventually, dear liar, you’re going to be feeling quite squirmy, and she’s going to be calmly sitting across from you with one more bland, open-ended question ready to ask. A good interviewer on the scent of a lie is a lovely and terrible thing to watch.

Really, the way to lie is to go bawlz-out and tell a whopper. (Apologies for the gendered reference, but the opposite is equally vulgar and a bit too serial killer.) You can make up the details as you go, and there are no conflicts, as long as you don’t go on too long. The Nazis, vile bastards that they were, were right on that one.

Which brings us back to a point above. Arpie is not a psychopath. Psychopathy is, roughly speaking, lack of a conscience – a sort of wired-in incapacity to treat anyone else as more than a means to your own ends. People who are highly psychopathic will look at such an interaction as a game to be played for a win, and the win is getting what they want; or getting away with it once they have it. They will have no qualms about telling great big lies, even to someone who cares about them. That internal dissonance wouldn’t be there, because to such a person, lying is a matter of strategy and tactics, not morality.

So, to sum up, in order to lie effectively:

  1. Lie to someone who isn’t paying attention (Usually easy).
  2. Tell a whopper (Hard if you’re not a psychopath, so . . . ).
  3. Be a psychopath.

Under ordinary circumstances, only number 1 applies, which is the only reason most people get away with the lie.

Now this is short term. This is all about whether the lie is internally consistent – meaning somebody can pick it apart right there. The main reason I’m not nearly so bugged by lies nowadays is that I’ve learned that what works in the short term, is pretty much dead opposite to what works in the long term. 

To give a concrete example, once upon a time there was a patient who had a habit of coming into the ED in distress because various family members died in terrible ways. Everybody took him at face value, until he had gone through more grandmothers than a cat has lives.

Big ol’ whopper? Yup. Inattentive listener? Well, maybe that’s unfair, but the pace of most EDs is not conducive to deep curiosity. Yet, eventually, the big lie gets too big to fit in with the rest of reality.

The psychopath thing? The very thing psychopaths have going for them in the short run fails them in the long run. No matter how superficially disarming they are, they show their colors. Then nobody believes them. Even when they tell the truth.

So to make a lie work in the long run:

  1. Keep it simple, with the deception trivial, so that most details will fit reality and not lead anybody to be too curious.
  2. Don’t be a psychopath.

Lies mostly amuse me, now. This is not to say I haven’t swallowed some in my time, and I will no doubt swallow many more before I’m done. I don’t take it personally. The best goalie on earth is still going to let some through. I do take a certain delight in the game of detecting them. If I don’t catch it at first, though, usually all I have to do is wait and watch. The truth finds a way. 

Back to poor Arpie, squirming internally while trying to hold onto this program that really has made a world of difference in her life, staring right down the barrel of losing it because she’s in too deep. What is her way out, though? To admit she’s doing exactly what may cost her that program? 

And what about this Dr. C. character? There he sits, knowing the truth, but still going through this ritual. Isn’t it a little uncomfortably cat-and-mouse? Wouldn’t it be kinder to just come out and call bull#$@t, or even just drop the hammer and throw her out?

You’re right to wonder about him. He certainly does, from time to time. Maybe we should pick up this story later. Could be, there’s redemption to be had for all. That always makes for a better story.