Physicians as Unwitting Research Subjects

"We'd like to invite you to join your colleagues and thought leaders in the field for a discussion concerning a new treatment for major depression."

This sounds like something that a busy physician, trying to keep up with the latest developments in the field, might really benefit from.  I continue to get invitations that sound just like this one.  The group sponsoring such discussion groups is not usually identified clearly in the invitation, but if it is mentioned the name usually contains words like "medical education."  Of course, the sponsor does not formally offer the kind of Continuing Medical Education most physicians require for keeping their medical licenses.

When I was a young and somewhat naive psychiatrist back in the early 1980's, I responded to one of these invitations to learn about a new antidepressant called Desyrel (generic name: trazodone).  This medicine is used today primarily in low doses (25 -  150 mg.) as a non-addictive sleep medication because many people find it extremely sedating.  The anti-depressant dose, rarely prescribed because many people taking it have trouble staying awake, is 400 to 600 mg per day.  Consequently, many doctors don't think it is an effective antidepressant because they never prescribe anywhere near that much.

Desyrel came out in the years before the SSRI antidepressants like Prozac and Paxil were on the market, and many docs were looking for alternatives to tricyclics like Elavil or imipramine, and MAO inhibitors like Nardil, since those medications often cause a lot of side effects and are also fatal if taken in overdose.  The real sponsor of the discussion group - the pharmaceutical company making Desyrel - was well aware of this and was looking for the best ways to take advantage of this situation in order to increase the number of prescriptions being written for its new drug. 

And not just by having doctors learn about the drug.

In fact, the real and covert reason for sponsering such discussion groups in the first place is to study physician behavior.  Of course, I did not know that at the time.  The drug companies were putting doctors under the microscope to determine the best ways of marketing their products.  They still do this, and they are very good at it.

Looking back, I remember the "leader" of the discussion asking the panel, "If I told you that Desyrel works much faster than tricyclics, would that be something that would be important to you?"  Since anti-depressants, when they work for Major Depressive Disorder, do not begin to kick in for about two weeks, and do not provide their full benefits until five to six weeks have elapsed, this would indeed be a fine selling point.

"Of course," most of the members of the now quite excited discussion group replied.

Since then, almost every new antidepressant, up to and including the latest one called Viibyrd, has made the claim that it has an earlier onset of action than all the others. 

For the record, none of them actually does.

The pharmaceutical industry shows particular interest in discussion group members who seem reluctant to endorse their new product.  These folks become objects of more intense study.  The group leaders probe these persons to find out exactly what might convince them to prescribe the new pill.  How can they best appeal to them?  Feed their ego in some way?  Preach patient convenience?  Which side effects are they most concerned about? 

The answers to these questions are not only used to develop overall strategies for pharmaceutical sales reps to use with reluctant prescribers, but are also used to compile information on individual physicians in the area, so sales reps can prepare themselves with a plan that is highly tailored to each physician. The plan is then used on the unsuspecting practitioner to help increase the number of prescriptions for their drug that that doctor writes.

The success of the reps is then monitored by the company by studying the prescribing practices of the given physician.  This information is readily available from local pharmacies unless the physician knows that he or she can opt out of allowing pharmacies to sell their information, as I described in a previous post.

Getting Significant Others to Tell You the Truth Part I Judgments Masquerading as Descriptions

As I have mentioned in many posts in this blog, the key to effective problem solving for dysfunctional families is to initiate metacommunication (talking about the nature and manifestations of rules by which the family operates, as well as talking about the way the family communicates), and then learning how to do it effectively.  Many strategies were discussed previously in my two series, Ve Have Vays of Making You Talk and How to Disarm a Borderline.  


Many of the strategies described in the Disarm posts need not be limited to dealing with family members who have significant borderline behavior, but work well on anyone trying to avoid telling you that they are purposely frustrating you because they do not want you to pursue certain lines of questioning.


In this new series of two posts, I will describe situations in which individuals with whom one is attempting metacommunication seem to be answering the questions that have been posed to them but are, in actuality, avoiding answering the questions.

In the second, upcoming post I will describe a strategy used by people who do not want to tell you their real motives for why they did or did not do something - thereby blocking your efforts to understand them and their motives better: descriptions masquerading as explanations.

In this post, I will cover a problem that crops up when one family member questions another family member about his or her relationship with a third party.  I call it judgments masquerading as descriptions.

This applies in situations in which the goal for the metacommunicator is to avoid being triangulated into the relationship of two other family members who are at war with one another.  According to family systems theory, when any two family members are having an unstable relationship, they will often rope in a third party as a sort of buffer.  


Two of the three members of the triangle may seem to gang up on the third, but there is usually much more to the story than that.  If deemed necessary, the alliances can quickly shift, so that the person ganged up upon can suddenly join either of the other two parties to gang up on the third, who had previously been allied with the other member of the triangle.  The goal of triangulation is avoidance of the underlying conflict, not its solution.


In the process of roping in a potential triangulee, so to speak, one of the original warring dyad – will call him #1 - will tell stories about the other (#2) designed to provoke outrage at #2.  #2 will be said to have engaged in some dastardly behavior or other. 

In this situation, in order to prevent triangulation, The metacommunicator (#3) should then try to get a more complete description of what has transpired, to make sure that #1 is not leaving out any information that might change #3’s perspective about both the events in question and the reasons why #2 may have reacted the way he or she did. 


When first asked about a particular interactional relationship episode, #1 may  respond with a rather global judgment about the other person involved rather than a specific description of what actually took place. 

A woman, for example, might describe her father as “controlling.”  Unless #3 knows precisely what she means by “controlling,” he or she is in no position to judge whether this characterization is accurate.  #3 might have a very different conception about what constitutes “controlling” behavior and what does not, as well as about what behavior it is that the father might be attempting to “control.”  


A typical scenario in which #3 might conclude that he or she is being misled might go something like this: #1 states globally that her father tries to control whatever she does.  Dad might, unbeknownst to #3, call her incessantly on her cell phone whenever she goes out on a date.  Upon further inquiry or observation, however, #3 learns that the father bankrolls his daughter’s every whim, no matter how reckless, whenever she asks him for money.  #3 then draws the incorrect conclusion that the patient’s characterization of the father as “controlling” is completely distorted.

           

Notice something peculiar in this particular case.  If #1 knows that #3 may come to know facts which would call into question #1’s “judgment” about #2, then the goal of #1 may be to provoke #3 into siding with #2!  In other words, the goal of the triangulators may be to create a situation in which two people gang up against them!!  Also, if #2 creates the situation in a way that keeps it rather ambiguous as to exactly who did what to whom, this allows #2 to manipulate the triangle so that the potential metacommunicator can be provoked to change sides several times over the course of a long period of time, depending on what seems useful at the time the switch is provoked.

In order to avoid this scenario, it is important to find out exactly what behavior the father engages in that leads #2 to use the term “controlling.”  In other words, what specific behaviors and suspected motives of the father are entailed by #2’s use of the term?  Even people whom most others would find very power-oriented do not try to control absolutely everything that their family members do.  They would not in most instances care, for example, what time family members brushed their teeth. 


In this case, for example, the father is attempting to control his daughter's dating life, while letting her do whatever she wants in most other areas of her life.  In fact, he seems to be enabling her to do what she wants in those other areas.  So the judgment "controlling" is both correct and incorrect simultaneously.  Nobody is one was all of the time when it comes to almost any conceivable characteristic.  To think otherwise is black-or-white thinking, or "splitting" if you will.

#3 must be a good investigative reporter and ask for specifics using follow-upquestions.  He or she should ask for detailed examples of misbehavior by other family members, and run down implied but unspoken implications.  In the above case of a judgment masquerading as a description, #3 should ask for illustrative examples.  He or she could ask, “What exactly is your father trying to make you do or not do?”  If #2 responds with another global generalization such as, “Everything!” #3 should persistently ask for some prototypical examples.  


After an example of an interaction is finally given, it may still be necessary to ask for further clarification: Exactly how did the father’s behavior lead #2 to conclude that he wanted to control one of her activities?  The father’s statements as reported by #2 may sound relatively innocuous to #3, but such may not be the case.  #3 might ask, “What was it about that statement that made you think that he does not want you to get married?”

To summarize, to find out what #2 really means, #3 needs to ask for behavioral descriptions, not just the patient’s opinions regarding the other person's personalities. Metacommunicators must ask follow-up questions. They can ask for clarification of vague or confusing statements and inquire about seemingly insinuated but unspoken implications. 


To continue with the example a woman who described her father as “controlling,” the metacommunicator would learn much by asking the patient the following additional questions: What do you mean, in behavioral terms, by “controlling”? What is your father doing and saying that indicate that he wants to control you? What do you believe to be his motives for wanting such control, and on what do you base this belief? What part of your life do you think he wants to control? What exactly is he trying to get you to do or not do? How does he go about trying to control these aspects of your life? Under what circumstances does he act in such a manner, and under what circumstances does he not act that way? What are you doing or saying that might be provoking a “controlling” response?

In obtaining concrete descriptions of interactions rather than globalized judgments, it is also important to find out what the people in the described relationship vignettes actually said to one another. Finding out specifically who said exactly what to whom in reported conversations that were conflictual, adversarial, or anxiety-provoking for someone often adds a tremendous amount to a person’s understanding. Family members who may otherwise omit important details often are able to provide very accurate details of affect-rich conversations because such conversations are so emotionally salient for them. 

One should try also to elicit as much as possible about the whole conversation, not just a part of it. In particular, the way conflictual conversations end may provide important details about the patterns of mutual invalidation that often characterize poor communication in families. Statements such as “Mom did not respond at all after I told her that” are ambiguous and should trigger further requests for clarification. What did Mom actually do at the point of “no response”? It is impossible to not behave.  


Did Mom turn around and walk out of the room? Stare silently into space as if in a trance? Roll up into a fetal position? The answer to such questions allows #3 to better understand #2’s need for avoidance and ambiguity in their discussions of important issues.

The more specific and detailed the questions you ask, the more accurate the picture of the other’s relationships becomes.

Psychological Problems in Kids and Teens New Study Looks at Parental Discord as a Major Cause

One of the recurring themes of this blog is the tendency of mental health researchers and practitioners to look at patients' symptoms without any investigation into the home environment, and decide that they, or their brains, are the entire problem.

Psychological problems in kids are roughly divided into externalizing behaviors and internalizing behavior. The former is basically acting out: doing poorly in school, being hyperactive, being oppositional, getting  into fights, throwing tantrums and the like. 

The latter refers to things like anxiety and depression. Either way, today kids who have any of these problems are in danger of being labeled with mental disorders such as ADHD, bipolar disorder, and even "oppositional defiant disorder," which I refer to as "spoiled brat disorder." And of course there is "conduct disorder," which I refer to as "juvenile delinquency."

These know-nothing researchers act as if living in a tense or chaotic home environment is good for children's emotional life and that they do not become distractible or agitated under these circumstances.

As I have often joked, when it comes to looking at the home environment, most mental health professions will - if they say anything at all - label it as "within normal limits (WNL)." What WNL usually really means is "We never looked." If they do "look," they may ask the parents one or two questions about discipline, and take their answers at face value as well as valid or complete.

Or if they really want to pretend they have obtained the whole picture, they can ask the child's teacher what the kid's behavior is like at school. Of course, teachers are likely to have less patience with kids who are distractible, and then have lower expectations of them. The kids will pick up on this, and the teacher's attitude causes these kids to become even more distressed, which makes the teacher have even less patience and lower expectations of them, and so on in a vicious circle. (This long-term process was described by Peter M. Senge in his amazing book, The Fifth Discipline).

Researchers in psychiatry, as I described in a post about borderline personality disorder researchers, are even worse than practitioners at ruling out environmental causes as the explanation for symptomatic children. They never even read summaries of the literature produced by developmental psychologists.

One developmental psychologist, E. Mark Cummings, summed up quite nicely the type of results that this literature routinely shows . He was quoted in a recent article in the Atlantic (http://www.theatlantic.com/education/archive/2016/10/the-effects-of-a-simmering-parental-grudge/503015/#article-comments) that described a recent study ("The Multiple Faces of Interparental Conflict: Implications for Cascades of Children's Insecurity and Externalizing Problems,"  P.T. Davies, R.F. Hentges, J.L. Coe; E.M. Cummings, Journal of Abnormal Psychology [in press]):

“Children are like emotional geiger counters,” said E. Mark Cummings, a professor of psychology at the University of Notre Dame who has conducted extensive studies on the effects of marital discord on kids for more than 20 years. Children, he explained, are incredibly attuned to parents’ emotional communication with each other; they’re keenly aware that, for their parents, nonverbal expression is key to communicating feelings.

For many couples, holding onto a grudge—smoldering but not letting a disagreement erupt into a fighting match—may seem like the best way to deal with a conflict. But research shows this kind of discord can significantly interfere with a child’s behavior and sense of emotional security. When exposed to prolonged unresolved conflict, kids are more likely to get into fights with their peers at school and show signs of distress, anger, and hostility. They may also have trouble sleeping at night, which can undermine their academic performance. In fact, according to various studies that measured children’s emotional responses to interparental hostility, disengagement and uncooperative discord between couples has shown to increase a child’s risk of psychological problems, including depression, anxiety, social withdrawal, and aggression."

Here is the abstract of the study. Notice how the study was longitudinal - meaning it looked at parental behavior and children's reactions to it over an extended period of time - and used multiple measures and multiple observers. Researchers also actually observed the family members interacting with one another while engaged in various conflict resolution tasks. That's what a researcher has to do to in order vastly improve his or her chances to see what is really going on at home and to see what the most important causal factors are for psychological distress in young people.

This multistudy article examined the relative strength of mediational pathways involving hostile, disengaged, and uncooperative forms of interparental conflict, children's emotional insecurity, and their externalizing problems across 2 longitudinal studies. Participants in Study 1 consisted of 243 preschool children (M age = 4.60 years) and their parents, whereas Study 2 consisted of 263 adolescents (M age = 12.62 years) and their parents. Both studies utilized multimethod, multi-informant assessment batteries within a longitudinal design with 3 measurement occasions. Across both studies, lagged, autoregressive tests of the mediational paths revealed that interparental hostility was a significantly stronger predictor of the prospective cascade of children's insecurity and externalizing problems than interparental disengagement and low levels of interparental cooperation. Findings further indicated that interparental disengagement was a stronger predictor of the insecurity pathway than was low interparental cooperation for the sample of adolescents in Study 2. Results are discussed in relation to how they inform and advance developmental models of family risk.