The Freier Problem

Freier is a Yiddish word in common use in Israel. It’s hard to translate. Roughly it means “sucker”, but with a particular connotation; you aren’t a sucker because you are dumb or unlucky but because you follow the rules when everyone else knows that the rules are only for freiers. While a person might be proud to be called upstanding, moral, law-abiding nobody wants to be a freier. (For a great discussion of three possible origins for the word see Balashon’s post).

The word captures a complex set of tensions that people struggle with in relationships; familial, work, neighbourhood etc. People generally want to view themselves as good. But they also desperately do not want to be the last person upholding a norm that everyone else gave up on a long time ago. I roll my eyes or huff indignantly if one person cuts in line, but if there is no line, just a bunch of people shoving, then standing and waiting just feels foolish. If I am honest about how much I earn when I file my taxes I may feel good about doing my part, but if I learn that no one else is being honest, then I start to feel contempt for myself.

Philosophers have discussed situations in which collective action will offer a big benefit but individuals may act to pursue lesser gains at a cost to the whole. Two examples are “the Stag Hunt” or “the Prisoner’s Dilemma.” In those scenarios if someone loses, the loss is material and the players have no way of communicating with one another.

But I often see couples facing “the Freier Problem.” They can talk to one another. The material costs of investing in the relationship are relatively low and the material costs of getting their elbows up and fighting more is high. Yet each of them sits there looking at the other person to make changes. Why double down on behaviour that they know hurts the relationship?

When I ask people they say; “It will be so humiliating to be the only one working for this relationship.” And that is what makes Freier problems so tough. The cost of being a freier is psychological more than it is material. A much more important force than material loss is at stake; the fear that I will despise myself or be viewed with contempt by my partner or my community.

We are facing a whole variety of Freier Problems as a society. Public health measures against COVID-19 are a perfect example. Yes, there are real costs in either complying with restrictions or not. But much of what drives people is the fear of being seen as badly behaved or contrariwise, the fear of being a freier, being the last person to wear a mask, to stay home from work, to maintain social distance.

"You can't do affect with a still face"

A client recently pointed me in the direction of Diana Fosha and her work on trauma recovery. She comes from a psychoanalytic perspective which is very different than my own training and orientation, and I didn’t know anything about her so I went online and did a little digging. I read a little of her work and I saw that she has her own method called Accelerated Experiential Dynamic Psychotherapy (AEDP).

I really like to hear a therapist talk about their work. It is hard for me to take seriously the insights of a therapist who seems like a jerk, to whom I wouldn’t send a friend or loved one. Hearing the person talk gives me a sense of what it would be like to sit in a room with them as a client. I found this example.

She was warm and personable and very smart and it seemed clear that she spent a lot of time with actual clients and was not solely involved with research. I left the video on while I tidied up in the kitchen. At 7 and a half minutes she said something that made me put down the dishcloth, go over to my computer, and scan back and really listen. And then listen again. She was talking about therapist neutrality and she said: “You can’t do affect with a still face.”

There is a lot in this. Affect is the outward expression of emotion, both what a person says verbally about their mood and all the subtle clues we give off about how we are feeling. So right away she is talking about a therapist who isn’t only focussed on what I say about how I feel but on what I express about how I feel, unmediated by words. One of the limits of talk therapy is talking. It seems pretty evident that some stuff in our minds is harder to get at by talking. Most people have the experience of trying to share an experience with someone else and finding words are insufficient. Therapies that rely only on talk miss important dimensions of human experience. Unfortunately, many manualized therapies are very cognitively oriented, so they often leave out what is harder to articulate or even inarticulable. Psychoanalytic therapy is notoriously ‘talky’ as the client or analysand talks to the quiet, almost silent analyst and slowly, slowly moves to articulate what has been unarticulated, the realm of affect.

The still face is a reference to Ed Tronick’s work on attachment. Briefly, Tronick developed the still face experiment as a way of evoking attachment responses in infants by having the mother show no affect. The video can be hard to watch, so be warned.

Fosha is connecting the affectless parent in Tronick’s experiment to the neutral therapist who refuses to engage on an affective level with a client. This prompted me to think about when I do and don’t connect affectively with clients, when I allow myself to be an engaged, caring part of a two person system, and when and how I hold myself back. It can be hard, now that I am doing therapy remotely, showing concern, caring, warmth to a screen or sending positive regard through a telephone line. Watching this reminded me of how healing the presence of a caring, capable other can feel.

I work on a Mac. I know that when I look at my client’s face, I am not actually looking directly at them and I worry about deepening what can already feel like a gulf. But above my screen are the little round green light and round camera lens. We are so hardwired to find faces that if I squint my eyes, the two odd circles can look like a mismatched pair of eyes, my client’s real eyes, not their virtual eyes. That’s where I look sometimes when I particularly hope to pierce through the ether and isolation and send my client closeness, warmth and regard in the hopes of healing.

Great Resource for Anxiety for People of Any Age

So here’s my theory about Lawrence J Cohen’s great book “The Opposite of Worry: The Playful Parenting Approach to Childhood Anxiety and Fears.” He wrote a book for anxious parents and then decided he would have more luck getting them to read it if he said it was for helping their kids be less anxious.

I love the title and for that alone is worth it; the absence of anxiety isn’t the opposite of anxiety. Feeling playful, full of creativity, joyful as when we are goofing around with someone we love that is the opposite of anxiety. Cohen really emphasizes parents and kids feeling connected rather than simply focusing on behaviour, something I really appreciate.

The book is full of great, practical approaches to anxiety that anyone can use. Hug yourself when feeling anxious, wrap both arms over the opposite shoulder, alternate pats or squeezes on the opposite shoulder. It feels warm and embracing, it requires a little cognitive and kinaesthetic work, so it takes us out of our anxiety, it is easy to remember for a person who is feeling freaked out.

It also contains a lot of wisdom addressed to anxious parents (a.k.a. the part of ourselves that might think other people’s anxiety is a problem but our own is absolutely reasonable and the only thing keeping us together.)

“If you know you are safe, but you still feel anxious, then you may welcome a chance to lower your anxiety. If you believe you are in danger, however, then it would be foolish to relax. You need to be prepared to act at a moment’s notice. That’s why some highly anxious children angrily reject suggestions to relax. Abe [a] boy who was ... afraid of thunderstorms, once said to his mother, ‘three deep breaths are not going to stop us from being hit by lightning’”

Finally, Cohen takes a very humble and humane attitude towards his clients, friends, family and himself in this book; he is definitely not the all-knowing therapist who understands clients much better than they can understand themselves. He learns from kids and parents alike about how to manage anxiety.

Do we marry the wrong people?

An article about "How We End Up Marrying the Wrong People" in the Philosopher's Mail is wonderfully thought provoking, full of great insights and very wrong.  I probably should agree with it since it recommends that people undergo lots of self-reflection and guided psychological processes before they get married.  In fact, the last line is a call for "psychological marriages."  Sounds like it would be good for business. 

The good.  

The article -- which, oddly, is unsigned -- has many fantastic observations about relationships.

“We ‘project’ a range of perfections into the beloved on the basis of only a little evidence. In elaborating a whole personality from a few small – but hugely evocative – details, we are doing for the inner character of a person what our eyes naturally do with the sketch of a face.
We don’t see this as a picture of someone who has no nostrils, eight strands of hair and no eyelashes. Without even noticing that we are doing it, we fill in the missing parts. Our brains are primed to take tiny visual hints and construct entire figures from them – and we do the same when it comes to the character of our prospective spouse. We are – much more than we give ourselves credit for, and to our great cost – inveterate artists of elaboration.”

This is a lovely way of showing us how much we project onto our partners.  I spend a lot of time with couples trying to get people to disentangle what they want or fear or expect from their partners, from what their partners are actually saying or doing or feeling. 

“Prior to marriage, we’re rarely involved in dynamics that properly hold up a mirror to our disturbances. Whenever more casual relationships threaten to reveal the ‘difficult’ side of our natures, we tend to blame the partner – and call it a day. As for our friends, they predictably don’t care enough about us to have any motive to probe our real selves. They only want a nice evening out. Therefore, we end up blind to the awkward sides of our natures.”

In my experience, both personal and professional this is true.  Couplehood can make us to examine our faults because there is a lot at stake.  But is knowing oneself a prerequisite for a good marriage?  Of course a publication called the Philosopher's Mail thinks so.  Me, not so much.  

The Mistake

What follows from this smart, though pessimistic, view of human nature and relationships -- that a battery of psychological testing prior to marriage will enhance self-knowledge and knowledge of the other person and thereby fix what ails marriages -- is a mistake.  A whopper of a mistake.  A mistake on the order of picking a life-partner with eight strands of hair and no nostrils. 

The mistake is that it both underestimates and overestimates what psychology is. 

I recently saw a couple who had been married for 25 years in which the man was completely resistant to all my psychological blandishments, he wasn't hostile or 'in denial' or 'defended'; he just was completely uninterested in his own motivations.  As he saw it, over the course of a long marriage, he had forgotten to treat his wife well and now he wanted a chance to do what she was asking for; more attention, more romance, more sex.  I wanted to know 'why' but after three sessions he had changed and she was happy.  The surgery was a disaster but the patient not only survived but felt much better.  The lesson: Who cares 'why' if a relationship works?  There are plenty of couples who are happy enough, for enough of the time that they don't need to spend a lot of time reflecting on it.  (This is one of the great discoveries of John Gottman's research).  It is easy to extrapolate from unhappy couples in a therapist's office to assume that all couples are unhappy.  The dubious statistic (Philosopher's Mail, thankfully does not) about 50% failed marriages can re-enforce this idea (for why the statistic needs to be taken with a grain of salt see here).  Even if we grant it for a moment that 50% of marriages will last sixty years, it is worth noting that the vast majority do so without without anybody ever stepping into a shrink's office.  As I have remarked before, marriages, like people, are resilient.  A realistically optimistic focus on individual and couple resiliency is honest and healthy. 

The most serious problems people encounter in couples are not magnifications of the same problems they encounter in friendships or the work place.  The reason for that is that a couple relationship isn't the same as other relationships.  I see a lot of young couples, couples who have recently moved in together after a year or two of dating.  They fight, they hurt.  They come in bewildered because what they are experiencing is so different from what happens in the rest of their lives and what happened for the first year of their relationship. 

From what I have seen, after a year or two in a relationship, if and when we feel safe with our partners people sometimes do something different than they do in other relationships such as friendships.  My metaphor for this is: we come to our partner timidly, expectantly, filled with hope and reach out to them and offer them a beautiful silver platter filled with our shit.  When we feel safe and loved and secure enough we bring out things that we haven't paid attention to or thought about or reflected on for years, things that we are ashamed of, afraid of, mistrustful of, don't have any idea how to handle.  It is a paradox that the tribute of love is our own least loved parts.  These are things that psychological testing won't discover.  And our partner's reaction to us offering up our damaged bits can't be easily predicted. 

Couples can and should talk about their expectations: money, career, housework, children, sex.  People need to be honest with themselves about what is important in a partner but also need to know that will change over time. 

I don't believe in compatibility so much as I believe in kindness, flexibility and positivity.  Those qualities will see couples over a lot of hard stuff including a lot of incompatibility.  

Therapy: who decides?

Nobody knows why therapy helps.  We have theories but no solid understanding of the mechanisms involved and we probably won't for a long time. Therapy isn't alone in this. Nobody knows, for example, why SSRIs, a commonly prescribed class of anti-depressant works either.

We do know that for certain categories of psychological problems -- some couple and family distress, mild to moderate depression or anxiety, certain personality disorders, and some psychotic disorders -- psychotherapy helps a significant portion of people and has minimal down sides (there are possible negative consequences to therapy some of which I discussed here).

These two points -- that therapy works and that we don't know why it works -- are important to emphasize because government and private insurance are increasingly involved in the practice of psychotherapy.  An example; this week the Order of Psychologists of Quebec announced that it is proceeding against two people for practicing psychotherapy without a license.  Here, in Quebec, since 2012 you must have a license from the Order to offer psychotherapy, which is defined as follows...

“A psychological treatment for a mental disorder, behavioural disturbance or other problem resulting in psychological suffering or distress, and has as its purpose to foster significant changes in the client’s cognitive, emotional or behavioural functioning, interpersonal relations, personality or health. Such treatment goes beyond help aimed at dealing with everyday difficulties and beyond a support or counselling role.”

Clearly, the provincial government is taking psychotherapy more seriously.  Also it is clear that it is hard for lawyers to write a good definition of a process that we don't understand very well.  How far in can the government wade?  So far it has been restrictive legislation.  André Picard of the Globe and Mail, who writes as well as anybody in Canada about psychiatry, mental health and mental illness, has written a very good piece aimed at beginning (again) a discussion around the funding of psychotherapy through public health insurance.  Currently, no provincial government funds non-MD-provided psychotherapy in the same way that it funds medical procedures.  Here in Quebec, non-MDs -- psychologists, social workers, creative arts therapists sexologists etc. -- who work as psychotherapists in the public sector get paid a salary through their institution, they don't charge per procedure.  They are also increasingly rare.  The vast majority of out-patient psychotherapy is provided by private practitioners for whom clients pay out-of-pocket and either get reimbursed by their private insurance or not.  This means that people who might greatly benefit from psychotherapy but can't afford it are unable to access it.  The more seriously mentally ill a person is the more likely it is that he or she is poor, and the less likely it is that he or she has private insurance so this way of delivering non-emergency mental health care is seriously off. 

I like the idea of people being able to access psychotherapy regardless of income.  But I have some serious reservations about the idea of public health care funding for psychotherapy.

1. Psychotherapy is one thing that can help with mental illness.  There are lots of other non-medical treatments that can help the mentally ill: stable, supportive housing is a big one; case management is another.  If we want to spend billions helping the mentally ill do better in the hopes that we will benefit as a society, we need to take these two as seriously as psychotherapy and medication. 

2. It can be a bonanza for some and create rich, entrenched interests that distort psychotherapy.  Research into psychotherapy can make for very dispiriting reading. It often looks like this; I have developed Wexler's Wonder Therapy (TM).  I test WWT (TM) on people with depression by giving them 8 sessions.  I exclude from my study anybody who has a drinking problem, couples problems, a history of childhood trauma, depression that has been treatment resistant or anyone with a cat because these other factors would confuse the research.  I begin with 15 people who meet these criteria.  Six drop out.  Of the remaining nine, six experience greater relief than they would if they were on a waiting list.  Wexler's Wonder Therapy (TM) is 67% effective!  It works on non-drinking, non-childhood trauma, non-treatment resistant, non-cat owning depressed people in only 8 sessions so it is incredibly cost effective.  It becomes the treatment standard for psychotherapy for depression.  I will train clinicians in WWT (TM) for a mere 1200$.  With that money I prove that WWT (TM) is also effective for anxiety and couples difficulties.  And so on.  This is not to say that psychotherapy isn't effective.  It is.  But for many conditions there does not seem to be much daylight between different therapies.  And people are a lot more complex in clinical settings than in research trials, which means that claims to deliver highly-effective, short-term psychotherapies are often over-hyped.

3. Psychotherapy isn't medicine. These difficulties come of trying to shoehorn psychotherapy, and psychological care generally, into a medical model.  Psychotherapy is connected to medicine because of its origins and because there is real overlap, but it isn't the same thing and trying to use our health-care system to pay for it means putting a square peg in a round hole.

4. It seems very unlikely to happen.  Quebec is in the midst of cutting hundreds of millions of dollars from its health care system and psychiatric outpatient care is being hit hard.  Proposals to take on additional expenses seem likely to be DOA here and elsewhere. 

I want to ensure that people who need non-emergency psychological care can get it regardless of income and at the same time maintain a practice of psychotherapy that is flexible and not overly bureaucratized.  Here is a suggestion: borrow from the Americans, specifically Obamacare.  Rather than expand Medicare to include non-hospital psychological treatment, require private insurance companies (which are making billions of dollars a year) to offer all Canadians 25$/year mental health insurance plans.  No cherry-picking, no pre-existing condition exclusions.  All plans must cover the cost of non-hospital services like psychotherapy, case management and emergency supportive housing.  Require all Canadians to have a mental health insurance plan.  Plans that do a good job of keeping policy holders out of hospital for a year get a portion of the cost of saved hospital psychiatric care.  Incentivize non-hospital based psychological care and let groups of clinicians experiment with what gives the best results.  This is  probably more likely to happen than provincial governments finding a few 100-million$ a year in spare change at the back of the couch and might preserve some creativity and flexibility in psychotherapy as well as ensuring non-psychotherapeutic treatments are on the table when necessary.  

Resistance is where the work begins

Ginger Campbell host of the Brain Science podcast, after a great interview with Norman Doidge about neuro-plasticity, said that doctors often don't prescribe behavioral therapies because they have the experience of patients not following through (1:05:00). "Many patients would rather take pills than follow treatment regimens that require them to do most of the work themselves."  I will write about Doidge at some point soon, but I thought a lot about Ginger's statement about homework and follow through. 

Recently, I have been finding that the most interesting moments in therapy come when I ask a client to try something that he/she/they won't or don't do and we unpack that resistance.  I have said before that on a handful of occasions, I have given people really good advice in therapy.  But much more common are people who know more or less what they need to do to make changes in their lives but resist it for reasons they cannot fully understand. 

I recently told a client who was feeling ambivalent about his marriage -- he couldn't commit to it and couldn't leave --  that he should try being fully invested in his relationship for 3 months.  At the end he could still leave or stay or continue being undecided, but in order to see what the relationship might be, he should try actually working at making it good for a limited amount of time.  He physically writhed at the idea.  He almost began to twitch.  What makes committing to the relationship, even provisionally, so hard? 

I told a couple that they should spend ten minutes a day talking about something tough in the day and supporting one another.  When I asked them about the exercise he said, "It feels weird because we see each other all day, she knows everything about my day."  They began to see how her being available to him for almost all his emotional needs throughout the day was not so great for their relationship. 

I told a client to meditate so that he could be a little more present to his partner.  "Sitting still for ten minutes is my idea of hell," he said.  She began to cry because she wants him to be able to be still for her.  It turns out that he has missed some crucial hurt feelings of hers because sitting still with emotions is so painful for him. 

People have reasons for not changing.  Sometimes it is a cost benefit analysis: "This requires a lot of work and I don't have enough confidence that it will make a difference."  I think a lack of confidence that medical science actually knows what is good for us is an important and neglected part of that cost benefit analysis.  It is hard to take your doctor's prescription seriously if you don't think s/he understands what is going on with you and what you want.  That doesn't come in 15 minutes.  Sometimes the road to such confidence comes from taking the time to unpack what else makes change hard.  

It is ironic that most doctors probably know that just prescribing behavioral change is unlikely to get people on board, yet they still do it.  Another opportunity to ask the question, "What makes it hard to do this?" And perhaps the beginning of real change. 

Making Humans

When I worked in inpatient psych the stories people would tell me were always a mix of sadness and joy, brokenness and resilience, the ways family can heal and hurt, sometimes simultaneously, back and forth across generations.  Drugs, what we call -- for lack of a better term -- mental illness and plain old human hurt wound together so tight the divisions between them become indistinguishable, the things that bring people into hospital are always part of a story of a family, trying, failing and succeeding in various ways to hold a human soul.  The CBC radio documentary "Tragedy Builds a New Family" from the Sunday Edition took me back to that. 

Burkhard Bilger's piece about kids riding bulls, "The Ride of their Lives" in Oklahoma and Texas in this week's New Yorker provides a fantastic illustration of how kids can grow and thrive in all sorts of lives and how our ideas about what childhood 'should' be are circumscribed by our tribe.

“I thought about a playground near my house in Brooklyn, in Park Slope. A couple of years ago, it was beautifully renovated by the city, with a rock-lined stream meandering through it and an old-fashioned pump that children could crank to set the water flowing. The stream was the delight of the neighborhood for a while, thronged with kids splashing through the shallows and floating sticks down the current. Yet some parents were appalled. The rocks were a menace, they declared. The edges were too sharp, the surfaces too slippery. A child could fall and crack her skull. “I actually kept tapping them to check if they were really rocks,” one commenter wrote on the Park Slope Parents Web site. “It seemed odd to me to have big rocks in a playground.” Within two weeks, a stonemason had been brought in to grind the edges down. The protests continued. One mother called a personal-injury lawyer about forcing the city to remove the rocks. Another suggested that something be done to “soften” them. “I am actually dreading the summer because of those rocks,” still another complained.

The parents at the camp flipped this attitude on its head. They valued courage over caution, grit over sensitivity. They revelled in the raw physicality of boys. The mothers sat in the bleachers taking videos and hollering advice—“Wyatt, just ride the way Daddy taught you!” The fathers straddled the chute, leaning over their sons to cinch the rope and shove the calf into position: “Are you ready?” “Yes, sir!” “You’ve got to take the fight to him.” “Yes, sir!” “You’ve got to want it.” When the gate blew open, they leaped up on the rail and watched their sons with clenched fists and narrowed eyes. They weren’t stage parents, for the most part. They just took following your bliss to its logical extreme. “I’d let my kid do whatever he has a passion for,” one mother told me, “even if he wanted to be a piano player.””

— New Yorker

"Even if he wanted to become a piano player" instantly become a piece of shorthand at my house. 

Finally, I have been thinking about that stupid bromide "It takes a village to raise a child," because of the reaction that has been prompted by two similar law-suits filed by people who have left hasidic communities, one just outside of Montreal (Mike Finnerty conducted a really thoughtful interview with Yohanan Lowen, the man formerly of the Tosh community; you can get there if you follow the link to audio).    I don't write about it much, but I have spent a lot of time working with ultra-Orthodox Jews in various settings.  One thing that the reaction to these two stories illustrates to me is how confused we (by that I mean everyone who isn't an ultra-orthodox Jew or part of some other tight-knit, small traditional community) are about 'community.'  We value 'community' in the abstract, we love to say "it takes a village to raise a child" but we have little experience of the travails of living in a village.  Someone I know who grew up in Grenada told me that if he did something wrong at school he would get spanked by the teacher and then when he walked home, the neighbour-ladies on his street would see him come by, crying, and each in turn would call him by name up to their front porch and each one would give him yet another spanking because they knew why he was crying "You didn't listen to the teacher?"  To me this is a perfect illustration of the mixed-blessings of growing up in a village.  Tight-knit communities are tight-knit because people feel responsible for one another and entitled to enforce compliance to community standards, in particular when it comes to kids.  They coerce people to act right.  They are conservative; they do not value change and are wary of outside ideas and different people.  Some communities are more like this, some less but you can't have maximum individualism and still eat the cake of a shared set of values and communal responsibility.  There is a reason people are leaving villages all over the world; we live in an age where personal expression and individualism are more important than adhering to norms set by the past and our neighbours. 

Three angles on how those around us grow us up into who we are. 

Review: Saving Normal by Allen Frances

I recently heard the wonderful Ginger Campbell interview Allen Frances on the Brain Science podcast.  Almost before my headphones were off I had run out to buy Frances' book "Saving Normal, an insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life."  Frances clearly and humanely outlines his case that "The cruelest paradox of psychiatric treatment is that those who need it often don't get it, while those who do get it often don't need it." 

I had some concern, even after the very thoughtful interview on BSP, that this would be a soft-headed screed against psychiatry.  I know a lot of people who have benefited from mental health treatment including psychiatric medication, and I think it is very wrong to frighten people away from psychiatry who really can use it.  I needn't have worried. Frances is a psychiatrist with a great love for the profession and confidence in the good it can do.  He is absolutely committed to the idea that psychiatry can be beneficial to seriously mentally ill people and at pains to illustrate that.

But he is also clear-sighted about the failings of psychiatry and medicine generally (he is very much talking about the US situation.  I will reflect a little on the Quebec context below).  The big failing Frances takes on is 'diagnostic inflation.'  He means the tendency to expand the criteria that are used to diagnose mental illness, either by loosening criteria for exiting illnesses or by 'discovering' new illnesses.  What prompted this call was the American Psychiatric Association's process to issue a fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM.  Frances thinks the authors are too quick to expand definitions which will inevitably lead drug companies to step in and push for meds for people who could do without them.  Frances is in a good position to comment because he was in charge of the DSM-4.  He is very up front about his own failings in having lead that installment and apologizes for his mistakes.  It is extraordinarily refreshing to hear someone with such a level of authority offer a public apology. 

One of the diagnostic overreaches that he addresses is 'psychosis risk syndrome'.  We are close to being able to identify people who are at high risk of developing psychotic disorders like schizophrenia.  We know many of the risk factors including certain genetic markers, we think that delaying onset of schizophrenia means being less sick and we know that being very sick with schizophrenia is very hard.  Why not target teens who are at elevated risk and are exhibiting "prodrome" symptoms; self-isolation, quirky or aggressive behaviour in the hopes of forestalling or even preventing the onset?  Frances gives a very good answer to that.  First of all, target them with what?  The answer will probably be anti-psychotic medication.  We have no indication that taking anti-psychotics before developing psychosis will help stave off or mitigate the effects of schizophrenia and the side effects can be very serious, including obesity and diabetes and everything that comes with that.  And, he points out, we can identify teens who are at risk, but that would probably involve identifying a lot of kids who will never develop the disease and potentially subjecting them to this very serious intervention.  It begins to look a lot like the aggressive screening and treatment of prostate cancer, too many people, too invasive for limited benefit.  Frances doesn't mention the possibility that teens who are identified might benefit from interventions that have less potential downside like counseling about delaying use of street drugs including marijuana and psycho-education about reality testing.  Given the way Quebec is headed, it seems unlikely that we will see a targeted public health campaign that relies on disease prevention using labour-intensive methods like psychoeducation.  

Frances also alludes to something I have mentioned elsewhere in this blog; namely that not all conditions of the human soul are diseases in any recognizable sense and yet increasingly the DSM includes them.  The idea that mild to moderate depression, or attention deficit disorder, or anxiety is a neurochemical imbalance fits very nicely with a drug company's bottom line.  The emphasis of the last twenty years on neuroscience has tilted us towards a chemical fix for ailments of the mind.  Yet not one significant advance in diagnosis or treatment of mental illness has come out of all the important research on neuroscience so far.  Diagnosis remains entirely symptom-based.  The mechanisms for the function of treatments is poorly understood, if at all. 

“All of this may seem very much like “inside baseball” for people who don’t spend their days thinking about mental health but Frances makes a persuasive case that a lot of people are already getting a lot of powerful psychiatric medication that they don’t need...”

All of this may seem very much like "inside baseball" for people who don't spend their days thinking about  mental health but Frances makes a persuasive case that a lot of people are already getting a lot of powerful psychiatric medication that they don't need, medicines with serious side-effects that may not have been adequately tested on the populations for whom they are being prescribed.  He reports that the sale of anti-psychotic drugs at $18 billion (US) now delivers more cash to the pharmaceutical industry than anti-depressants.  Anyone who has any experience with them knows anti-psychotics are powerful medications with very serious potential side-effects.  They are helpful to people with psychosis.  But now they are being marketed for use with children and the elderly.  20% of people treated by primary care physicians for anxiety now receive an anti-psychotic as well, according to Frances.  The trend towards GPs prescribing psycho-active medication is troubling for Frances as well.  That GPs give out anti-depressants and anti-anxiety medications routinely should surprise no one, but I was amazed to learn that 50% of anti-psychotics are prescribed by GPs.  (I am not sure if that accounts for GPs taking over the prescription of anti-psychotics after an initial prescription by a psychiatrist.)  Frances goes through the familiar litany of the dangers and over-promises regarding SSRIs for treating the 'worried-well' market.  These are problems we see here in Quebec, though certainly not to the degree they are experienced in the US. 

Whose fault is all of this?  For Frances the answer is pretty clear.  Big Pharma and the big money it is willing to throw around to advertise direct to consumers (only in the US and -- apparently -- New Zealand as well), to co-opt the better judgement of doctors and researchers as well as to fight legal battles and pay fines when they get caught behaving badly (as with the off-label marketing of anti-psychotics for kids).  He gives policy recommendations for taming the excesses of big pharma.  Naturally, dear to my heart are all the plugs that he makes for psychotherapy as an alternative or adjunct to pharmacology. 

“There is no organized psychotherapy industry to mount a concerted competitive push-back against the excessive use of drugs.”

— Saving Normal

Here in Quebec, we are retrenching from any kind of public outpatient psychotherapy, at great cost to our well-being, I believe.  It is nearly impossible in Montreal to get psychotherapy at a CLSC (public health and social service clinic).  This despite the fact that we know that psychotherapy can sometimes head off   episodes of serious mental illness later for certain people and keep them from needing much more expensive hospital care.  Follow-up care after a psychiatric hospitalization is spotty and seems unlikely to get better with more cuts coming. 

“The lack of a credible alternative is part of what is fueling the appetite for drugs. If we want to see the biomedical model of mental illness restored to a more modest role and with it the role of psychotropic medication, we need to take seriously the challenge of collectively creating a psychotherapy that is credible to the people it can help. ”

While I am a believer in psychotherapy, if I have a quibble with Frances, it is over this.  My experience is that many psychiatrists and other psychotherapists have been and continue to be high-handed, overly jargonistic, faddish, opaque and sometimes deeply anti-scientific.  Frances himself mentions the terribly misguided satanic ritual abuse accusations of the 1990s and the role played by therapists who "developed and instant expertise on day care sex."  Many people mistrust us because they view psychotherapy as elitist mumbo-jumbo that changes tack every ten years.  All those primary care doctors who are prescribing medications rather than sending their patients to therapists don't trust talk therapy.  Why should patients?  Hell, I have met quite a few psychiatrists who don't have faith in psychotherapy.  The lack of a credible alternative is part of what is fueling the appetite for drugs.  If we want to see the biomedical model of mental illness restored to a more modest role and with it the role of psychotropic medication, we need to take seriously the challenge of collectively creating a psychotherapy that is credible to the people it can help.