down the rabbit hole…

Posted on Monday 8 July 2013

There is only so much mileage to be gained from discussing a 20+ year old legal case and the square-off between Drs. Klerman and Stone. For those of us living through those days, it can’t help but bring up the feelings from that time. And if you have access to the literature, the published articles in 1990 that I reported [respecting our limits…] weren’t the end of things. Each of them had a subsequent letter in the American Journal of Psychiatry in March 1991, and those latter exchanges felt more like a dart game with human targets than a debate. There was a lot of that going around back then.

It was a desperately polarized time. There was a brand new game in town, and you were either on the bus or off of the bus. As much as people tried to frame things in terms of science and proof, it sure felt like a lot of it was biology versus psychology [and money] at the time. And things like this statement from Dr. Klerman rang from every tower:

Traditional psychotherapy could never meet such a test. That was a given. The result was that psychotherapy wasn’t going to be included in the domain of insured medical practice, an important subtext of all of these debates and arguments. I don’t think anyone knew then how generally constricted the role of psychiatrists would ultimately become back in those days. And from another vantage, reading it now, this is the part that stands out and strikes me as a dreadful irony:

I know why he said it then. "Look Dr. Stone, if you’re so hot on psychotherapy – prove it. That’s your job, not ours!" But looking at the comment now twenty-three years later, and after spending a few of my own years thumbing through countless industry·funded, industry·run clinical drug trials that have been so regularly buggered with, it feels almost like a conflict·of·interest·manifesto. They generated their own evidence all right – often whether it was there or not.

It’s easy in reading articles like these to lose sight of Dr. Osherhoff, the patient in the center of this story. As I’ve thought about his case outside the context of the legal battle, it’s beginning to look different to me. Though we are not given a lot about his history, we do know that he seemed to have a primary difficulty in relationships. He had three marriages before age 42, each with something of a whirlwind courtship and a fiery breakup – each breakup precipitating a major personal crisis requiring professional help. We also know that he had conflicts with his practice partners. At the time of his hospitalization, he was embroiled in just such a crisis during the breakup of his third marriage. And for the second time, it happened when children came into the picture. Two possible diagnoses come to mind – an undiagnosed manic depressive illness that might account for his changing states and strained relationships. Marital crises are common in the history in such cases. Another real possibility would be a personality disorder in the borderline spectrum where recurrent crises in close relationships are the sine qua non of the condition. In the latter case, the regressive therapy would be expected to make things decidedly worse – which is exactly what happened. For that matter, that approach wouldn’t do much for a manic depressive illness either. I’m speculating on minimal information here, but my suspicion is that this great showdown between psychoanalysis and pharmacotherapy built around this case was a contrived debate. The clinical problem was much more likely what it usually is when a case goes this badly – an incorrect diagnosis.

I generally shy away from these cosmic debates. For one thing, listening to them for thirty plus years wears on the soul. I’ve heard them so much that I think I could take either side and come off as credible. They generally end up like this one – ad hominem banter that escalate to no useful end. So I have to ask myself why I even got so interested in the Osherhoff case. I think anything from that period when psychiatry was undergoing such an upheaval captures my attention. We were all so busy then with our internal sword-play that we didn’t attend to the coups d’état by external forces that shaped the present far more than anything we had to say to each other. Clinical Trials were touted as the triumph of evidence based medicine over alchemy rather than the conduit for corruption they became. The promise of medications that were helpful but hardly curative became first a gold standard, then the only possible solution, now sometimes framed as vilified toxins. A case like Dr. Osherhoff’s elevated a botched diagnosis to an ideological debate on the front page of our first line journal. And needed reform of our hospitals ended up sending many of our chronic patients back to the prisons they’d escaped centuries ago, closing needed facilities along with the snake pits.

I seem to think that rehashing how we got here will help me see the things I didn’t see [and feel like I should have seen] back when this was all happening. I really didn’t see the corrupted medication trials in the wings and the rise of the KOLs. I reckon old people have done this since the dawn of time, writing things with titles like The Winds of War, The Gathering Storm, A Remembrance of Things Past – looking from afar to see what fell through the cracks up close. With me, it’s more than just a retrospective. It’s more like patients with PTSD who are trying to prevent the past [which is of course an impossibility]. They were taken out by something they weren’t prepared for, didn’t see. They spend their days on high alert, making the preparations for a second coming. In this case, my concern is that in solving the problems of today, we’ll just lay the base for another round with unacceptable collateral damages. Sometimes, today’s debates sound as contemptuous as Klerman v. Stone in 1990. And I worry that the leadership like the APA, its DSM-5 Task Force, and the NIMH are still running on inertia aiming for an idealized future and don’t see the skid marks all around them.

I suppose what I would hope for is more like a "mid-course correction" than another cataclysmic exorcism – something that puts the fate of the mentally ill on the front burner instead of their getting lost in the other forces that have more to do with the profession’s internals than the things we profess to be charged with doing. Things like AllTrials, RIAT, RxISK, ProPublica, the Sunshine Act all seem to me to be pointing in the direction of positive change and speak well of their proponents. They’re encouraging to say the least. But I’ll bet the next time I run across something from those days of the 1980s that I missed the first time around, it’ll be down the rabbit hole for me for another round…
    July 8, 2013 | 1:39 PM

    And I worry that the leadership like the APA, its DSM-5 Task Force, and the NIMH are still running on inertia aiming for an idealized future and don’t see the skid marks all around them.

    Mickey, thanks for the look back . . . it does seem to be one of the characteristics of advancing age. We ask what could we have done, what should we have seen . . . and hope that our years of experience can somehow be shared and passed on so the new generation won’t make OUR mistakes.

    Perhaps I’ve shared this post from the Mercola website before. I read it (before animation) years ago, and was struck by the breadth of the message. I’m sure many have seen it . . . but the readership expands, contracts and changes over time, so I’ll post a link for those who want to see a cartoon version of SKIDMARKS disease.

    hat tip to Melody
    July 8, 2013 | 3:18 PM

    War terminology is appropriate. The trial, as you point out, was an aggressive ideological maneuver. The problems of the day were reduced to absurdity, so that in time, the scientific and clinical manifestation of the field was reduced to the same absurdity, as well.

    Revolutions eat their children. What was missing from the battle cry of biolgocal psychiatry was the voices of patients— though plenty was heard from their families through astro-turfed organizations like NAMI. The agency, legitimacy, experience, and evaluation of the effectiveness of treatments from the patients’ points of view were removed from the arsenal. An epidemic of disability was the result and the poisoning of the public mind which created more stigma and disinformation about mental illness, the mentally ill, and those labelled as mentally ill, even as the crusaders of biological psychiatrists were claiming the mantle of public advocates.

    July 9, 2013 | 8:13 AM

    It seems that borderline spectrum issues are often diagnosed by their negative response to psychotherapy. I’m wary of this process, because it practice it doesn’t seem all that different than “unmasking” of bipolar through by a manic episode brought on by taking SSRIs. If we don’t think SSRIs are actually useful in diagnosing bipolar, and that manic responses are induced by the treatment itself, why not think a negative response to psychotherapy is just that, instead of a diagnostic tool that unmasked a previously undiagnosed personality disorder? Both diagnostics through treatments approaches seem to let clinicians off the hook by then introducing more serious and stigmatizing diagnoses of their patients. Maybe the pills were too much or too quickly added, maybe the psychotherapist messed something up, but nope, the patient must have bipolar or be borderline of our treatment of choice makes them worse.

    July 9, 2013 | 8:28 AM

    Interesting comment, though I’m unclear about how it fits here. My speculations about diagnosis were based on his history, not his response to treatment. Am I missing something?

    July 9, 2013 | 5:51 PM

    You noted that his Osheroff’s negative response to regressive psychotherapy would be expected if he had a borderline personality disorder/organization. This is using his experience in treatment as part of your speculative diagnosis. Presumeably, the staff at the Chestnut Lodge also had knowledge of his prior history and I’m sure got quite a bit more than what is publicly known during his time there. With their understanding of his history and symptoms, they came to the diagnosis of a narcissistic personality disorder. Same history, different diagnosis, and a diagnosis that to my knowledge many analytic thinkers would say is really only helped by intensive exploratory psychotherapy or analysis. Whether or not your speculation is correct or the Lodge’s initial diagnosis stands, I don’t see your kind of speculation inclusive of history and treatment response different than someone with depressive symptoms coming to a psychiatrist, having a solid history taken and being given antidepressants for a diagnosed depressive illness, and then after having manic symptoms, is then told has bipolar disorder that was unmasked by the antidepressants.

    To my understanding, it seems that the Chestnut Lodge staff were as capable of psychiatric diagnosis as any psychiatrists (regardless of the validity or reliability of diagnosis at the time), and chose a treatment method that was reasonable for their diagnostic appraisal. I agree that their diagnosis was probably wrong, but it does not make it ok that the treatment they initiated made things worse and then now we use that treatment experience to to then change diagnosis, instead of taking responsibility for the choice of treatment (which they only kind of did).

    So I think I am getting at that I think we need to be similarly critical of the way we think about response to psychotherapy as we do to pharmaceuticals. If we believe drugs may initiate worsened conditions (ex. SSRI-induced mania) that is not a reflection of someone’s supposed pathology (ex. a patient’s depression in not undiagnosed bipoloar), then similarly worsened conditions brought on by psychotherapeutic treatment (increased agitation/psychosis/decompensation/etc. brought on by analytic psychotherapy) should not be considered part of someone’s supposed pathology (ex. a depressed patient who experiences such worsening does not have a serious personality disorder).

    Treatments can have unintended and harmful effects, as well as be less likely to be helpful than published data indicate. That’s the risk of intervening in anyway. I wish psychotherapists would take that risk as seriously with their interventions as many here believe should be with biologic treatment. In both accounts, poor scientific support and clinician error/misjudgement should be considered fairly in assessing negative response as much as patient factors (if not more). I just don’t like seeing negative responses being chalked up to misdiagnosis or more severe character pathology when there are plenty of other possible factors on the clinician side that then go unaddressed.

    July 9, 2013 | 9:26 PM


    For what it’s worth, I expected to hear from you when I wrote this post. You were in the my mind as I wrote it based on your earlier comments. My thoughts about Dr. Osherhoff’s diagnosis were based on his history, not on his response to treatment. I know that because they occurred inside this head. They came while I was reading Dr. Stone’s paper describing his marriages and their crises:

    You noted that his Osheroff’s negative response to regressive psychotherapy would be expected if he had a borderline personality disorder/organization. This is using his experience in treatment as part of your speculative diagnosis.

    I don’t agree with that, but that’s not worth litigating. I at least know my own thoughts. It was later that the possibility of regression in treatment occurred to me.

    I’m well aware that when people with my background speculate, it bothers you a lot – pathologizing, stigmatizing, blaming the victim, not considering iatrogenic illness, projecting our own pathology into patients, etc. I gather that you’ve seen a lot of that and the damage it can do. So have I. If you don’t think I personally take that kind of thing seriously, I’d appreciate your pointing me to your evidence for that opinion.

    July 10, 2013 | 12:07 AM


    I believe your conversation with Dr. Sandra Steingard a few posts ago primed me to notice this. I was struck by the ease in which we can talk about some criticisms of unsupported myths like SSRIs “unmasking” bipolar disorder, but we seem to not so overtly address similar myths on non-pharmacologic treatment paradigms.

    You know your thoughts better than I do. You also did write:

    “Another real possibility would be a personality disorder in the borderline spectrum where recurrent crises in close relationships are the sine qua non of the condition. In the latter case, the regressive therapy would be expected to make things decidedly to worse – which is exactly what happened.”

    This seems to me in reflection tie a history of recurrent problems in close relationships and a negative treatment response to exploratory psychotherapy to a speculative rediagnosis of a personality disorder on the borderline spectrum. It may not be how you thought about in sequence, but in writing, to me, it seemed like a reasonable conclusion someone would draw when looking at patient’s life and treatment history.I just wanted to point out that this line of thinking felt similar to the thinking that led to rediagnoses of depression to bipolar due to manic symtpoms in some people who take SSRIs, and that I think it is important to apply the reasoned critique of such thinking across mental health treatment.

    I do believe you take such concerns of iatrogenic harm of psychotherapy seriously. It is no secret, however, that the vast majority of your posts are related to exploring problems in the biomedical paradigm. I believe you are engaged in a really important endeavor in your blog. I just want to make more overt that a lot of critiques explored here can apply to more than just the biomedical model (which I think can be lost when examinations of a particular model is so thoroughly explored), because I know you are concerned about the state of mental health treatment across the board. A post about one of the most important cases that (artificially) pitted major paradigms of treatment against each other at a critical time also seemed like an appropriate one to interject such observation.

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