The Psychiatrist in the Security Clearance Process

Transcription

Washington Psychiatrist
WINTER 2014
Now that we are ringing in the New Year
It’s time to Make The Right Choice.
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Washington Psychiatrist
WINTER 2014
President’s Column • Gary J. Soverow, MD........................................................... 2
Letter from the Editor • Gerald P. Perman, MD, DLFAPA ......................................... 3
WPS Officers
Gary Soverow, MD, DLFAPA
President
Steven Epstein, MD, FAPA
President-Elect
Avram Mack, MD
Past-President
Farooq Mohyuddin, MD
Secretary
Carol Trippitelli, MD
Treasurer
Published by:
Gerald Perman, MD, DLFAPA
Editor
Patricia H. Troy, CAE
Project Management
Betsy Earley
Graphic Design
Anne Benjamin
Web Design and Flipbook
For advertising sales, contact Debra
Mowbray at 410-490-7252 or email at
[email protected].
Parity Arrives on January 1. Are You Ready?
Shannon Hall, Executive Director, DC Behavioral Health Association....................... 4
Security Clearance Investigations and the Practice of Psychiatric Treatment
Barry J. Landau, MD. ......................................................................................... 8
The Psychiatrist in the Security Clearance Process
Brian Crowley, MD, DLFAPA................................................................................. 11
Ethical Issues in Pediatric Psychiatric Clinical Trials
Adelaide Robb, MD........................................................................................... 13
Defense Mechanisms in the 21st Century
Jerome S. Blackburn, MD, DFAPA, FACPsa. ........................................................... 16
There is More to the Story: Clinical Experience With TMS
Gary Spivack, MD............................................................................................. 21
Save the Date: WPS Calendar of Events................................................. Back Cover
.
About the Cover
Jan Hicks has been a creative person in one
form or another for many years. Her first
love was creating with her hands—cross
stitch, knitting, crochet and then paper
scrapbooking. She then discovered digital
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Through her love for scrapbooking, she
discovered a love for photography.
She can be found on Fine Art America at
http://fineartamerica.com/profiles/janhicks.html?tab=artwork and on Facebook
at Jan Hicks Creates, https://www.facebook.
com/janhickscreates. Visit her gallery and
take a journey of discovery through her eyes.
Submit articles and artwork for
consideration to [email protected].
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550M Ritchie Highway, #271
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PRESIDENT’S COLUMN
I return once more to the topic of dismaying trends that have arisen in our field. This one
plagues the rest of medicine as well, but more so in psychiatry because of our rightfully
fluid diagnostic boundaries. I will term this problem “diagnostic drift.”
By Gary J. Soverow
MD, DLFAPA
This occurs, I believe, once a powerfully effective treatment is developed for a widespread
and debilitating disorder. Once such a serious condition has been successfully brought
under good control, there is an understandable tendency to expand the patient population
subject to this beneficial intervention. Diagnostic criteria are modified to become more
inclusive. This is followed I believe by an unfortunate decrease in the response rate. A more
unfortunate result is that patients have then been exposed to more ineffective therapies,
suffer from a lack of successful treatment and therefore more unnecessary morbidity, including side effects with no benefits, and interference with return to full functioning.
This is the reason, I believe that rates of response and remission of major depressions,
bipolar disorder, and even schizophrenia have diminished so radically recently. I see many
patients in my office in this quandry. Adjustment in diagnosis, coupled with the corresponding change in somatic treatment often produce remarkable improvement. This is not through magic or a result
of any superiority of therapeutic skill.
Soon after I finished training, published studies reflected response rates to tricyclic antidepressants in patients with
what was then termed endogenous or psychotic depression of at least 60%. In other reports, these rates were over
80%. The efficacy of ECT in these cases was on the order of 85 to 95%. Such numbers apply also to patients with
true attention deficit disorders.
While I worked at St. Elizabeths on admitting ward, I saw many of the most severe bipolar patients. I never witnessed
a manic episode that didn’t respond to antipsychotic medications and lithium. Associated depressive phases were
exquisitely sensitive to antidepressants or ECT. Schizophrenic patients were not so fortunate, but many did respond
to antipsychotic agents with remision of their episodes. Some of course did not, but were not made worse by inappropriate interventions as I have observed in some outpatients who have come to me for treatment.
The reasons for this trend are many and varied. One could always blame our old bete noir, the drug companies, but I
think they take their lead from us. They benefit from diagnostic drift in that more medications are prescribed in succession or together. The ineffectiveness doesn’t have a negative effect on profits.
Another cause of this problem is, I believe, a result of the push for treatments of shorter duration, in both inpatient
and outpatient settings. This means less time is spent by the physician with the patients, making thoughtful diagnosis and therapy difficult, if not impossible. Insurance companies and government agencies continue to encourage further contraction of time and administration of therapy by less thoroughly trained practitioners. Relatives of
patients also prefer to hear a diagnosis with a more positive prognosis and some practitioners accommodate them
out of sympathy for their distress.
This state of affairs is compounded by current trends in the training of psychiatric residents. They may be supervised
more by senior psychiatrists who have bought into this thinking because of their own biases, which include reluctance to deal with certain types of patients and to employ some therapeutic modalities, especially psychotherapy.
Therefore, I see many patients in my office who suffer from schizophrenia or borderline personality disorders and
have been diagnosed as bipolar but not surprisingly have not responded to the traditional and effective treatments
for that condition.
This is, in my opinion, a serious and ongoing problem, but is amenable to rectification. It will require a change in
our thinking and a return to more rigorous diagnostic criteria. This will be opposed, of course, by entrenched interests in our own profession as well as in the insurance industry and in government who are more interested in reducing treatment expenditures without regard to the accompanying costs to our patients and to us. I think it is a battle
worth fighting. Our patients deserve nothing less.
an e-magazine
Gerald P. Perman, MD, DLFAPA
Editor
Dear WP Readers,
In this issue of Washington Psychiatrist you will find timely and informative articles on:
• the enactment of the mental health parity law
• opposing views about performing security evaluations on patients
• ethical considerations when children are asked to participate in clinical trials
• defense mechanisms that we are likely to ecounter in our patients in our psychotherapy
practices today
• a clinician’s report on transcranial magetic stimulation
In this and subsequent issues you will find publishing guidelines for Washington Psychiatrist articles.
Please email me your articles for consideration for publication in Washington Psychiatrist.
Thank you.
Cordial regards to all,
Gerald P. Perman, M.D.
Editor, Washington Psychiatrist
Parity Arrives on January 1:
Are You Ready?
By Ms. Shannon Hall, Executive Director
D.C. Behavioral Health Association
Introduction
Parity is coming to the District of Columbia on January 1, 2014. Parity is the principle
that mental health and addiction treatment is treated the same as medical coverage in
insurance decision-making.
This January, health plans in D.C. will have to expand their coverage of mental health
and addiction treatment, and we providers will have to adjust how we collect revenue for
our work. Just as insurance companies must alter their coverage, we must change our
practice to incorporate more work with insurance.
An Evolution of Enforcement Authority
We’ve been talking about parity for a long, long time. In 1996, Congress first passed the Mental Health Parity Act.
Its provisions were expanded in the Wellstone-Domenici Mental Health Parity & Addiction Equity Act of 2008.
Implementation began in 2010, when CMS released interim final regulations, but ground to a halt, when CMS
failed to issue final regulations. As a result, key parity terms—like the scope of services—remain undefined in the
interim final rule.
Parity was also included as a central component of the Patient Protection and Affordable Care Act, otherwise known
as Obamacare. The Act creates a greater role for state involvement in the definition and enforcement of parity. The
federal government laid out ten “Essential Health Benefits” that most commercial health plans will be required
to cover on January 1, 2014. Each state is then required to define this new set of benefits. Every state package of
Essential Health Benefits must include mental health and addiction treatment at parity, although each state may
create its own definition of parity.
As a result, it is now the state—not the federal government—that is now primarily responsible for defining and
enforcing parity. The federal government retains primary authority of self-funded, private sector health plans, but
state insurance commissioners have authority over all individual, small business and large group plans.
Advocacy to educate insurance commissioners about parity and their responsibility to implement it must shift to the
state level. Most importantly, states have become the primary enforcers of parity—and we must work to ensure that
oversight mechanisms in the District of Columbia are prepared to take up this role.
Who Gets Parity in the District of Columbia?
On January 1, most D.C. residents with health insurance will be enrolled in a plan required to cover mental health
and addiction treatment at parity. Today there are approximately 635,000 D.C. residents, all but 45,000 of whom will
have insurance on January 1, 2014.
The overwhelming majority of these individuals will, for the first time, be covered by a health plan required to meet
parity. This includes





Federal employees in federal health benefits;
n Employer-funded plans with 50+ employees (large group plans);
n Employer-funded plans with fewer than 50 employees (small group plans);
n Individual market plans; and
n Medicaid managed care programs.
n
The only health plans in the District of Columbia who will not be required to meet parity are the small number of
individuals insured through:
Church-sponsored or self-insured plans sponsored by state government;
Retiree-only plans;
n Individual or small business plans grandfathered in before January 1; and
n Medicaid fee-for-service plans.
n
n
Essential Health Benefits in the District of Columbia
The District of Columbia has adopted a broad definition of parity in its Essential Health Benefits, which greatly
expands the required coverage of behavioral health services by D.C. insurers.
Prior to the Exchange, existing D.C. law allowed treatment and day limits in behavioral health coverage (D.C. Code
§ 31-3100 et seq.). Health plans are currently only required to cover detoxification treatment for 12 days annually,
while inpatient substance abuse or mental health treatment is limited to 60 days per benefit period. Meanwhile,
outpatient behavioral health services are covered, but only as a fraction of the allowed medical benefit.
All of these limits must go away on January 1st. Instead, health plans must now cover “behavioral health inpatient
and outpatient services for mental health and substance use disorders without day or visit limitations.” Period.
Parity: A Working Definition
The working federal definition of parity is that a plan may not apply any financial requirement or treatment
limitation to MH/SUD benefits in any classification that is more restrictive than the predominant requirement or
limitation for substantially all medical/surgical benefits in the same classification.
Parity must be found in all aspects of benefit package. Absent a clear federal definition, many states are being urged
to re-examine many insurance decision-making tools in light of parity, including:
Copays, coinsurance, and out-of-pocket maximums;
Utilization limits and use of care management tools;
n Coverage of out-of-network providers; and
n Criteria for medical necessity (that also must be shared with beneficiaries and providers).
n
n
The New York State Psychiatric Association has alleged in a lawsuit that United Health violates parity by using
“concurrent reviews to prospectively limit and deny benefits for conditions that are, by definition, unpredictable.”
Meanwhile, the Connecticut Psychiatric Society has initiated a lawsuit alleging that Anthem violates parity through
restrictions on same-day payment restrictions, lower psychiatric reimbursements, and inadequate provider
networks.
One New Jersey provider called out Aetna’s coverage of inpatient addiction treatment. “Aetna does not wait until
someone is in stage four cancer before they treat him or her, nor do they tell a diabetic that has had a relapse, that
he or she is not worthy of care; yet the insurance company regularly penalizes those seeking addiction treatment for
not being sick enough, or motivated enough,” said the President of Seabrook House. He complained that the health
plans disregards American Society of Addiction Medicine Patient Placement Criteria and introduced burdensome
authorization processes.
None of these cases have yet reached clear resolutions, but they are signs of the behavioral health field’s increasing
impatience. The Affordable Care Act’s Essential Health Benefits gives us an exciting opportunity to work the D.C.
health officials to define and enforce these questions locally—and we must act to seize this opportunity.
You’ve Got to Change Too!
Insurers in the District of Columbia will be expanding their coverage of behavioral health services – and that means
that we, as a field, must change our practices. Too many of our members tell me that they don’t and won’t participate
in commercial or Medicaid managed care programs.
Our members, like mental health providers across the country, have traditionally focused their work on people with
disabilities—because this was the only population with a robust array of covered mental health services.
Health reform and the expansion of parity alters the array of insurance payors available to our field—and we must
alter our practices accordingly, even if it requires us to retool our offices, staffing and even our mission. These are
transformational times—and we must transform our work.
The D.C. Behavioral Health Association has tools to help providers make this shift. We offer in-depth briefings on
health reform, technical assistance, and classes on credentialing and paneling with health insurers. Contact us at
[email protected] to learn more.
Do You Want To Help?
The D.C. Behavioral Health Association is seeking to interview behavioral health providers who operate in the
following insurers’ networks: United, Kaiser Permanente, Aetna, BlueCross, [is this complete list of companies
participating in HBX?]. If you are currently an in-network provider for any of these plans and would be willing to
participate in 30-minute telephone interview, please contact us at [email protected].
Dear District Branch Member,
People with mental illness have long faced discrimination in health care through unjust and
often illegal barriers to treatment. Today, we congratulate the Obama Administration for
taking a significant step toward eliminating these barriers by issuing a Final Rule for the
Mental Health Parity and Addiction Equity Act of 2008. The Final Rule presents a crucial
action to ensure that our patients receive the benefits they deserve and to which they are
entitled under the law.
As the APA reviews the Final Rule to understand how it will impact the care of people with
mental and substance use disorders, we look forward to learning more about how strong
monitoring and enforcement will take place at the state and federal levels. Since passage of
the MHPAEA in 2008, the APA has played an active role in advocating for greater access to
quality mental health care by:
 testifying before Congress,
 participating in White House conferences on mental health,
 working to hold insurance companies accountable to the law though litigation and
assisting those impacted by violations in filing complaints with the Department of
Labor,
 joining and supporting the Parity Implementation Coalition, a group of professional
societies and advocacy organizations pressing for full enforcement of the law, and
 creating and distributing educational materials for providers and employers to better
understand the full impact of the law.
We ask you to join the APA in remaining vigilant and continuing to work toward true equity
for people with mental illnesses and addictions. To report problems with parity or other
practice management issues, call the APA Healthcare Systems & Financing HelpLine at (800)
343-4671 or send an email to [email protected].
More information is available at www.psychiatry.org/parity. Follow @APAPsychiatric and
#mhparity on Twitter to join the conversation on the final rule.
Sincerely,
Jeffrey A. Lieberman, MD
President, American Psychiatric Association
au, MD
J. Land
By Barry
One of the challenges of practicing psychiatry in the Washington, D.C. area is the perennial requests for
information pertaining to security clearance investigations. If the request is about a patient already in
treatment with him/her, the treating psychiatrist faces pressure from the security investigator whose
job it is to obtain all relevant information and who may believe that the treating psychiatrist possess
that type
of information.
Pressure also may come from the patient who needs the clearance for a job that
Preceding
Page:
Kent at
very
important to him and who feels compelled to waive confidentiality and to direct his therapist to
ageis20
in Haiti.
provide
the Twins
security
This
Page Top:
and investigator with whatever information he is asking for. The purpose of this article
is to
offer a mother
conceptual framework for a policy in which the treating psychiatrist would not participate
their
depressed
before
treatment.
in the
evaluative process involved with the security clearance of his/her patient.
Middle: Mad woman arriving.
Bottom: Trauma Seminar.
There are basically two issues that the treating psychiatrist needs to consider when approached by a security officer
for information about his patient pertaining to a security clearance investigation:
1. The issue of performing dual roles, that of therapist and that of evaluator for national security risks.
2. The role of confidentiality as a necessary condition that makes psychiatric therapy possible.
With regard to the issue of performing dual roles, when the psychiatrist is approached by a security officer, he/she
is in essence being asked to perform a psychiatric evaluation on his patient as to whether the patient could be a risk
to national security. If this request is about a patient whom one already has in treatment, then to perform such an
evaluation is to take on one role—that of evaluator—that is in conflict with another role—that of therapist—which
had already been established when the psychiatrist agreed to take on the patient in treatment. The treating psychiatrist’s attempt to provide an evaluative opinion as to the patient’s trustworthiness to protect the nation’s security
would risk degrading the treatment, since once the treating psychiatrist has done that, the patient’s communications
would likely be skewed so as not to tell the psychiatrist anything that the patient imagines might jeopardize his security clearance.
In such a situation, not only is the patient’s best interest served by having the psychiatrist decline to perform such an
evaluation. To be useful, any such evaluation of potential security risk must be done without regard to the patient’s
needs, interests, or welfare. The therapist’s evaluative opinion would inevitably be compromised because it would
be ethically and professionally impossible for him/her to provide such an evaluative opinion without paying at least
some attention to the needs of his patient.
Further, the treating psychiatrist in all likelihood has not really evaluated his patient as to the question of whether or
not he would be a security risk and thus would not have a solid basis for having such an evaluative opinion. Further
still, the psychotherapist tries to see things through the patient’s eyes and thus can have a subjectively skewed view
of the patient. By contrast, a consultant psychiatrist, seeing the patient explicitly for the purpose of evaluating the
risk to national security, will focus on objective data, including the possibility of obtaining corroborative data from
sources other than the patient, which the therapist may not be in a position to obtain. Thus, the federal government’s best interest is also served as well, since the evaluative function could then be delegated to another psychiatrist, who does not have therapeutic obligations to the patient, as well as having expertise in performing security risk
evaluations.
Regarding the issue of confidentiality, one of the clearest, as well as most authoritative, statements about the role of
confidentiality in psychotherapy can be found in the United States Supreme Court Jaffee-Redmond case, which in
1996 established an absolute psychotherapist-patient privilege. Not only do the statements in this case represent that
of the highest legal authority in the nation. In addition, they also represents a clinical consensus, since all the major
national mental health organizations submitted amicus briefs in agreement with each other, which the Court used in
developing its opinion in this case. The Court stated, “. . . the mere possibility of disclosure may impede development
of the confidential relationship necessary for successful treatment.”
In establishing the psychotherapist-patient privilege, the Supreme Court reasoned that, to provide effective psychotherapy, the therapist must be able to promise the patient that all disclosures will be kept confidential. Treatment by
a physician for physical ailments can be effective even if confidentiality is broken. The psychotherapist’s work cannot
be effective without the assurance of confidentiality. Furthermore, if the psychiatrist discloses, at some later time,
information that was originally said to be confidential, then confidentiality in fact never existed.
The psychotherapist-patient privilege that was established by the Supreme Court, and described above, is an unconditional one. That means that no matter how relevant for the trial the information from the psychotherapy is
deemed to be, the privilege holds and the judge may not over-rule or waive that privilege. Thus, the Justices weighed
the potential value of the psychotherapist’s testimony with the value of having confidential psychotherapy available
for citizens of the United States and came to the conclusion that confidentiality should prevail. Further still, as is
pointed out in the Jaffee-Redmond case, any information the psychiatrist does possess has likely been obtained only
on condition of confidentiality. Thus, the Justices conclude that any information kept out of trial because of the psywashington psychiatrist / winter 2014
chotherapist-patient privilege is not really being lost, since it would not exist without the promise of confidentiality.
The same reasoning applies to the security investigation.
There is a difference between a privilege, which pertains only to information that is requested during a trial, from
confidentiality, which is a professional agreement that is implicitly or explicitly promised to the patient by the treating psychiatrist, as a basis for conducting the treatment. However, the reasoning of the Supreme Court Justices in
establishing the psychotherapist-patient privilege applies directly to the rationale for maintaining patient confidentiality in the context of a security clearance investigation.
In taking the position outlined above, it is important for the psychiatrist to make clear that his declining to provide
an evaluative opinion should not in any way be taken pejoratively. It is a position based on the needs of the therapy
the psychiatrist is conducting, as well as the acknowledged constraints the psychiatrist would be under if he tried to
offer an evaluative opinion. It should not be taken to imply anything negative about the patient.
However, the Justices did envision one possible exception: That is, In the event that by-passing the privilege is the
only way to prevent imminent harm, the minimum amount of information necessary to prevent imminent harm
would need to be disclosed.
Of particular interest here, this exception pertains only if disclosing information from the therapy is the only way
to prevent imminent harm. Thus, it leaves room for the psychiatrist to exercise his/her professional judgment and
expertise. If harm can be prevented by other means, e.g. hospitalization, medication, mobilizing family, community
support systems, or in this case, the patient withdrawing his/her application for security clearance, then disclosure
would not be necessary.
In the event that the psychiatrist really does think that the patient would be a security risk, such a situation presents a dilemma that could challenge the most experienced psychiatrist. The position taken by the Supreme Court
justices pertains to imminent harm. However, a security clearance, once granted, can last for months or even years.
The treating psychiatrist also needs to take into consideration that the therapeutic relationship may be the most
important sources of support for the patient’s optimal mental and emotional functioning. There may really be no
thoroughly satisfactory answer to this problem. Ultimately, there is no substitute for a full and thorough evaluation
by an independent psychiatric consultant, with expertise in such evaluations. The best role for the treating psychiatrist in such circumstances may be to help the security investigator and the patient to appreciate the fact that, if he
has any question, then the best course of action is to have an independent, consulting psychiatrist, with expertise in
security evaluations, assess the patient.
In conclusion, when the psychiatrist receives a request for information about a patient he/she is treating in the
context of a security investigation, the psychiatrist needs to consider the issue of conflicts of interest in trying to
perform dual roles (or double agency) of therapist and evaluator, as well as the issue of patient confidentiality as a
necessary condition that makes effective psychotherapy possible. While each patient’s individual circumstance is
unique, and no one policy can anticipate every possible clinical situation, I hope that the concepts that I have presented above will be of help to the practicing psychiatrist who is trying to maintain patient confidentiality in what
can be a very challenging circumstance.
I would like to thank Drs. Paul Mosher of Albany and Dr. Norman A. Clemens of Cleveland, Ohio for reading drafts
of this article and for helping me think through this complicated issue. However, I take full responsibility for the
content of the article
10
The Psychiatrist in the
Security Clearance Process
By Brian Crowley, MD, DLFAPA
Psychiatrists are asked to participate in the security clearance process in either of two ways. First, treating psychiatrists are occasionally asked to give a professional opinion as to whether or not a patient, or former patient, is suitable for a security clearance. The doctor will receive a call or a fax from a federal investigator, usually asking to meet
briefly with the doctor, and stating he has a release signed by the patient. Typically only one question is asked:
Questionnaire for National Security Positions
Does the person under investigation have a condition that could impair his or her judgment, reliability, or ability to properly safeguard classified national security information?
q Yes q No
If so, describe the nature of the condition and the extent and duration of the impairment or treatment. ______________________________________________________________________
What is the prognosis?______________________________________________________________
Dates of treatment? ________________ Doctor’s Signature _____________________________
If the treating doctor answers that question “No,” that ends the inquiry and supports the patient on his way to obtain
(or retain) his clearance. On occasion a psychiatrist refuses to give any reply to this question. That refusal often leads
to a prolonged delay in adjudication, during which the patient/employee stays in limbo until the system makes a referral for a current evaluation by another psychiatrist or clinical psychologist. This delay, often lengthy, is a profound
disservice to an individual who is able, eager, and competent to work and to safeguard classified information.
I think we should answer this question for our patients when asked. Yes, we want to be sure the patient has consented to our giving this opinion, but he/she almost invariably has done so in writing, while looking for a new job, or for
advancement in an existing position. Most of the time these are folks who have been working with us in treatment,
sincerely trying to improve the quality of their lives and/or reduce symptoms. They are, in my experience, most
often earnest, sincere people with a high degree of dedication and patriotism. With a current patient, I make a point
always to discuss the inquiry I have received, and my proposed reply, with her/him before I meet with the investigator. (Frequently my patient has told me to expect such an inquiry, and we have already discussed it.)
On the other hand, if I am asked about a patient I saw once or twice, eight years ago, with dubious treatment commitment and a then-unstable condition, I say I do know not his/her current status and suggest a more current evaluation. While the form asks for a “yes” or “no” answer, there is absolutely no barrier to writing a brief explanation.
If a colleague will not answer that question about a patient he knows well out of fear his answer might prove wrong
and he will experience some backlash, he should critique himself for excessive timidity and/or lack of knowledge of
how strongly the law supports a doctor using his best judgment in the service of his patients and the community.
11
If uncertain how to handle a given inquiry, consultation with an experienced colleague is a very good idea, as it is
with other challenging practice situations.
In the second scenario, a psychiatrist is asked to perform an independent psychiatric evaluation for an individual
he has not met, addressing the issue of eligibility to obtain or to hold a security clearance. The evaluation may be
requested either by a government agency or by an individual; in the latter case, he/she is usually represented by an
attorney. Such an evaluation should be performed by a psychiatrist with considerable experience working at the
interface of psychiatry and the law. While this is a forensic psychiatric procedure, in my view it does not require that
the psychiatrist has taken a forensic fellowship – when I started working at the psychiatry/law interface there were
no such fellowships – but it does take one who has deep knowledge and appreciation for how the law undergirds all
psychiatric practice.
The doctor gathers all relevant information to understand the problems and issues presented, reviews the materials,
sees the individual (I recommend twice) in the office for personal evaluation, consults with appropriate parties as indicated, and writes a good report. The report need not be long but should be thoughtful, well-crafted, succinct, readable and interesting. In my experience, an 87-page forensic psychiatry report is almost always inferior to one that is
five-pages long. If the written report does not resolve the matter, a hearing will likely be scheduled to decide the case.
These hearings are usually held in a standard administrative hearing format with attorneys for both sides present.
Evidence is introduced, including expert as well as lay witnesses, and the hearing is presided over by an administrative law judge who makes a written ruling. It has been my experience that the individual regularly receives a fair
consideration in such a hearing, with ample opportunity to show eligibility to hold a clearance, and where problem
conditions are identified and mitigated.
In the federal government, the standard is the Adjudicative Guidelines for Determining Eligibility for Access to Classified Information. The Guidelines, promulgated by The White House, have been in use since the 1950s and revised
periodically through successive administrations. I find them clear, sensible, and nuanced – facilitating a quality
evaluation and report. The guidelines are more concerned with behavior than with formal diagnosis, and speak of
“behavior that casts doubt on an individual’s judgment, reliability, or trustworthiness.” “Conditions that could raise
a security concern and may be disqualifying” are balanced against “conditions that could mitigate security concerns”
in making the judgment to grant or deny a security clearance.
Importantly, the Guidelines provide explicitly that “No negative inference concerning the standards in this Guideline
may be raised solely on the basis of seeking mental health counseling.” This helps reduce the fear of some that being
in treatment is hazardous to their job health. In my long career I have found that this fear has not proven realistic.
In fact, it is just the reverse: leaving symptoms of mental disorder unattended to and untreated is hazardous to the
person’s standing at work as well as to the rest of his or her functioning in life. Employers generally would rather
have an employee who is productive and stable with ongoing treatment rather than an undiagnosed or untreated
bundle of behavioral dysfunction.
No specific mental health diagnoses, or behaviors, are listed in the Guidelines as automatically disqualifying. An
individuals is not deemed a security risk if that person has a psychological or behavioral problem and that condition
can be mitigated if “the identified condition is readily controllable with treatment, and the individual has demonstrated ongoing and consistent compliance with the treatment plan,” or there is “a recent opinion by a duly qualified
mental health professional employed by, or acceptable to and approved by the U.S. Government, that an individual’s
previous condition is under control or in remission, and has a low probability of recurrence or exacerbation.”
A number of my patients and former patients have gone on to serve with great credit and satisfaction in significant
jobs, after negotiating the security clearance process. On the forensic (evaluative) side, it continues to be interesting,
challenging yet rewarding work to conduct these evaluations and to participate in the adjudication process, including the administrative hearings.
12
Ethical Issues
in Pediatric
Psychiatric
Clinical Trials
By Adelaide Robb, MD
Over the last decade, the number of research trials investigating psychiatric medications for children and adolescents
has increased dramatically. Previously pediatric use was based on data from clinical trials in adults (Hoop, 2008). Adults
differ from children and adolescents significantly, including physical development, metabolism, effects and side effects
(McVoy and Findling, 2009; Laventhal, 2012). It would be naïve to believe that medications are effective and safe for
youth simply because they are effective for adults, and it would be irresponsible to act on this assumption. Fortunately,
researchers and practitioners acknowledged the paucity of data for psychopharmacological treatments for pediatric
psychiatric disorders and have implemented clinical trials designed to provide data (McVoy and Findling, 2009). This
research also brings to light ethical concerns with this doubly vulnerable population of children with psychiatric disorders. Researchers must strive to strike a balance between providing the data necessary to treat children and adolescents
with psychopharmacological agents and conducting ethical research with this vulnerable population.
A population is deemed as “vulnerable” in a research context when it does not possess the full capacity to consent to
research participation freely and knowingly and is at risk for being exploited (Hoop, 2008). Children and adolescents,
therefore, are considered to be vulnerable research populations since they are not legally able to make decisions for
themselves. A psychiatric disorder further reduces this decision-making ability, leaving youth with a psychiatric diagnosis doubly vulnerable. It is the responsibility of researchers and guardians to determine whether it is acceptable for a
child to participate in a trial. Federal regulations have been established to ensure that the rights and safety of children
are protected during research participation (Laventhal, 2012).
The federal government has determined four levels of risk for research protocols. The level of risk of a trial determines
the authorizations to be acquired during the informed consent process. Trials under the first level of risk are those that
pose no more than minimal risk to the participant, or no more than would be experienced by the patient in daily life.
These trials are not required to provide benefit to the participant, and the permission of one parent and the assent of
the child (if applicable) must be obtained. In the second level of risk, trials pose greater than minimal risk to the participants, but they also present the prospect of direct benefit to the individual. In these situations, the more-than-miniwashington psychiatrist / winter 2014
13
mal risk is justified by the anticipated benefit to the participant. Therefore, these trials must obtain permission from
one parent and the child’s assent to enroll a child in the study, although the child’s lack of assent can be overridden. The
third level of risk encompasses studies that pose greater than minimal risk to participants with no prospect of direct
benefit to them. Because risk outweighs benefit, permission for participation must be obtained from both parents in
addition to the child’s assent. These same requirements must be met by studies that fall under the fourth level of risk,
which involves studies that pose greater than a minor increase above minimal risk with no prospect of direct benefit
(Chen, 2009; Hoop, 2008; Laventhal, 2012).
In order to classify studies under one of the four levels, their potential risks and benefits must be assessed. Pediatric
psychiatric clinical trials may offer several potential benefits to participants. Participants may receive direct benefit from
being treated with an effective medication or therapy offered in the therapy arm of a study. If patients are randomized
to the placebo arm of a randomized controlled trial (RCT), they may not be receiving direct benefit from the drug being tested, but this does not mean that they are receiving no benefit from participating in the study. Many participants
in RCTs exhibit a “placebo effect,” or some helpful or therapeutic change in response to administering a placebo (Parellada, 2011; Rutherford, 2011). A participant’s conviction that they are on a medication often improves the symptoms
they exhibit. This seems to be especially true for children with depressive disorders, as Parellada et al. observed. In their
article on placebo effect and pediatric psychiatric trials, the authors state that “the degree of placebo response (not the
drug response) is the single most powerful predictor of drug superiority versus placebo in pediatric antidepressant
studies” (Parellada, 2011).
Many studies include regular check-up or monitoring visits, which provides the participant with routine care from
a psychiatrist. The amount children and adolescents benefit from “therapeutic contact” may be dependent on other
variables such as age. Rutherford et al. observed that the benefits of therapeutic contact are positively correlated with
patient age in pediatric depression trials. Because participation in pediatric research is time-consuming, clinical trials
frequently provide some form of compensation, usually monetary compensation. This sum should never be so excessive as to be potentially coercive by making families choose between participation and a much-needed financial bonus.
However, it often provides an additional benefit for participating in a clinical trial.
Of course, there are several risks posed by pediatric clinical research. A medication being tested may not be effective, or
well tolerated, causing adverse reactions. If confidentiality is breached, a participant’s diagnosis could be revealed to others, and participants may experience
stigma or discrimination because of this. Even if the child or adolescent is present for the consent and assent process, he or she may agree to participate without
fully understanding the purpose of the research or the risks they are undertaking
by participating in the trial. Children and adolescents may feel pressured by their
parents or other authority figures to participate without thoroughly understanding what it is they are getting into. This is only one of many ways that child and
adolescent research participants can be exploited.
Because these hazards exist in this type of research, certain safeguards are built
into the research process to ensure that these inherent risks are minimized or
eliminated whenever possible. One safeguard is the consent process. This process
should “ideally [be] a dynamic process of information sharing between participant or guardian and researcher” rather than merely the signing of a document
(Hoop, 2008). The discussion that takes place should help the parents or guardians and the participant make a fully informed decision regarding their participation in the study. Some researchers are concerned that the informed consent process has become overly burdensome and that the documents include too much
legal language, making them inappropriate for their audience. Researchers should
strive to make the documents and the consent discussion as straightforward as
possible to avoid any confusion or misunderstandings.
The researcher should use this opportunity to make sure that neither guardians nor participants are under the “therapeutic misconception,” which is when
participants believe that they are receiving the same benefits from research as they
14
would from medical care (Chen, 2009). The aims of these lines of work are far from the same; research is conducted to
benefit the whole of society by contributing to general scientific knowledge, whereas medical care’s purpose is to benefit
a sole individual. Hoop notes that “the desperation and hope experienced by parents of suffering children may make
them particularly susceptible to this misconception regarding their children’s research participation” (Hoop, 2008).
Therefore, it is even more critical that researchers conducting pediatric psychiatric clinical trials take the time during
the informed consent process to ensure that participants and their guardians understand all aspects of their participation in the research.
If the child participant is of a certain age and possesses a certain developmental capacity, it is necessary to acquire assent, another safeguard used in pediatric research, during the informed consent process. Assent is a child’s affirmative
agreement to participate in research; it is not enough for the child to simply fail to object to participation to say that
a child has given their assent (Chen, 2009; Laventhal, 2012). To make sure that a child or adolescent fully understands
what providing their assent means, it is critical that they play an equal role in the informed consent process and that
the discussion is brought down to a level that they can fully comprehend. To determine whether a child is capable of
providing assent, researchers generally follow the “Rule of 7s,” which uses a child’s developmental capacity to determine
whether it is necessary to acquire their assent. This rule assumes that children under the age of 7 normally do not have
the capacity to assent, that children between the ages of 7 and 14 have the capacity to assent, and that children older
than 14 have the capacity to participate in the informed consent process (Chen, 2009). This rule is generally followed
when it comes to pediatric research, but the clinical judgment of the researcher interacting with potential participants
and enrolling them in a particular trial should still be taken into consideration, as this will help ensure that the participant and their family do what is in their best interests (Chen, 2009).
A third safeguard utilized to minimize risks to child and adolescent participants in psychiatric clinical trials is the overseeing of every clinical trial by an outside data safety monitoring board. All research studies, regardless of their topic or
procedures, must be approved by an Investigational Review Board before enrolling participants, and federal regulations
require some studies that involve highly vulnerable populations (like pediatric psychiatric clinical trials) to have ongoing oversight by specialized committees called data safety and monitoring boards (DSMBs) (Hoop, 2008). These review
boards assess each study to ensure that they are ethical and minimize the amount of potential risk posed to participants. These bodies are composed of experts in the topic of the research and others with a variety of perspectives on the
research process, and the constituents of a board are autonomous from the researcher and the sponsor of the study to
ensure that its decisions are non-biased (Carandang, 2007). DSMBs follow each study under their oversight from protocol design to the end of data analysis, and they have the authority to require a research team to halt study procedures
at any point if they have reason to believe that the research has become unethical or more risky than originally planned.
Since pediatric participants with psychiatric illnesses are a doubly vulnerable population, some researchers have suggested that certain studies using this population as its subject pool be labeled as “high-risk” according to a particular set
of standards and that they be provided an extra layer of oversight (Carandang, 2007). Data safety monitoring boards
have been created with the sole intention of providing this protection.
Even with these safeguards in place, many concerns still remain regarding the ethics surrounding pediatric psychiatric
clinical trials. Even though national regulations have been created to guide ethical practices, it is often noted that different institutions and researchers variably interpret these regulations, making it difficult to guarantee that every research
protocol is held to the same ethical standards. Questions arise regarding “mature minors” who are clearly capable of
making decisions for themselves, but regulations requiring parental consent may prevent them from participating in
research that could provide them with direct benefits (Chen, 2009). Research is constantly branching in new directions
(i.e. genetic testing research), and these new directions inevitably raise ethical questions with which the research community has not had to deal (Laventhal, 2012). But these uncertainties should not deter researchers from investigating
unexplored topics and ideas, as the benefits generated by novel research have the potential to far outweigh the risks
involved. Regardless of whether they are exploring a new frontier or trying to replicate previous findings, researchers
must keep the basic tenets of ethical research at the forefront of their research practice. This responsibility is heightened
in the case of pediatric psychiatry research, but it should not discourage researchers from exploring the issues that need
to be addressed in order to provide the best care possible for children and adolescents with psychiatric disorders.
15
Defense Mechanisms in the 21st Century
By Jerome S. Blackman, MD, DFAPA, FACPsa
This article is a shortened version, reprinted with permission of the editor, of an article published in 2011 Synergy 16 (2):1-7
http://psychiatry.queensu.ca/assets/Synergy/Spring2011.pdf
“Defense mechanism” is a common term in the 21st century. Defenses can be found in language, entertainment,
humor, and literature. We use defense theory to explain various types of human behavior, thought, and psychopathology. Defenses inform the research of some neuroscientists. We can also use defense theory to refine ideas about
supportive and interpretive types of psychotherapy.
Defenses in Language, Music, Humor, and Organizations
We use the concept of defense in English idioms. For example, we reference specific defenses in expressions such
as: “The acorn doesn’t fall far from the tree,” referring to the defense of identification with parents; “He’s a glutton
for punishment,” referring to the defense of masochistic provocation—usually to relieve unconscious guilt; “I’m not
angry, you are!” referring to the defense of projection; “He’s a pushover!”—the defense of passivity.
Denial is mentioned in the country song lyrics, “call me Cleopatra…, Cause I’m the Queen of Denial1,” where the
singer observes that her fear of losing love has caused her to (defensively) overlook her lover’s negative character
traits. In a more serious vein, Alcoholics Anonymous’s Step 1 involves confronting alcoholics’ denial of addiction2, a
defense they had used to avoid shame.
Ideas about defense also are used by the Big Brothers3 organization that recognizes the need of fatherless boys to
have a kind, honest male with to interact. Once the boy felt attached to a Big Brother, the boy could identify with that
16
man’s value system (superego) and thus be better able to manage (i.e., defend against) delinquent (hostile-destructive) urges. And, of course, it is widely known that physically abused children tend to identify with the aggressor—they
may become abusive toward others as a way to avoid feeling angry and afraid regarding their own mistreatment. 4
In literature, Dave Barry, in his new book, I’ll Mature When I’m Dead5, jokes about trying to disentangle “the fivethousand-bulb string of [Christmas tree] lights that has, using its natural defense mechanism, wadded itself into
a dense snarl the size of a croquet ball.” (Italics added.) In addition, over 10 rock bands have put out a song called
“Defense Mechanism.”
So what are Defenses?
Brenner (19826) clarified that, clinically, every affect is made up of 1) a sensation + 2) a thought. We then define defense
as the mental operation that shuts out of consciousness the sensation (isolation), the thought (repression), or both.
Anxiety comprises an unpleasurable sensation plus a thought that loss, bodily harm, punishment, death, disorganization, humiliation, or failure will occur in the future. People with panic attacks experience the unpleasurable sensation, but the thought content is shut out of consciousness (repressed).
Depressive affect includes an unpleasurable sensation plus a thought that something terrible has already happened.
People who have lost a loved one but who are bottling up their emotions may develop irritability and sleep problems.
Typically, we formulate that they are aware of the thought content but not aware of the unpleasurable sensations.
What does Neuroscience have to say about Defenses?
Just a bit, but encouraging7. Anderson8 has delineated, using fMRI, that affects, generated in the limbic system and
hippocampus, are suppressed in the prefrontal cortex. This finding correlates with Brenner’s theory.
The Solmses9 indicate the limbic system and the hippocampal gyrus are implicated regarding affects.
Reiser (1999) correlated primary process (condensed, symbolic) thinking with findings from neuroscience. 10 The nature of consciousness and unconsciousness is poorly understood brain-wise. Gerald Edelman has studied memory,
but not the brain factors related to memory retrieval11 (after being forgotten).
Why would anyone use Defenses?
Defensive operations can be called up by the mind when the affect generated by reality or by inner conflict is intense.
For example, a male patient reported it was “no big deal” when, after a fall, he could not raise one arm up more than
parallel to the floor. I confronted his minimization; he then consulted an orthopedist and who performed rotator
cuff surgery.
A person’s capacity to withstand powerful affects may also be weak (borderline personality). After his wife realized
he was cheating on her, for example, a middle-aged man admitted guilt; but within days, he had sex with his girlfriend, and again confessed this to his wife. His therapist pointed out to him that he was provoking punishment (by
confessing to his wife) to relieve guilt; and using sexual intercourse with his girlfriend to relieve his pain over giving
her up.
Finally, an affect may be generated by a symbolic conflict. In sexual inhibitions and phobias, the mind responds to
symbolism as though the danger were real. A young married woman, for example, developed an acute phobia of
telephones. In treatment, she eventually remembered that after a fight with her husband, her old boyfriend from college had called to ask her out. She had responded that she was married but having problems, and that she would call
him back soon. At that moment, she had projected violent and sexual urges onto the telephone, and then avoided the
phone to avoid guilt. Once she realized all this, she was able to express her dissatisfactions to her husband.
Cinematic Defenses
Some movies depict defensive operations in their dramatis personae.
Narcissism as a way of avoiding (i.e., defending against) anxiety about emotional closeness is a theme in Eyes Wide
Shut (1999), Notting Hill (1999), Jerry Maguire (1996), and Closer (2004).
The Lion King involves multiple defenses. The protagonist, Simba, regresses, after his father’s death, by gallivanting
around with the warthog and the meerkat, in a “hakuna matata” (no worries) lifestyle, thereby avoiding his guilt and
depression over his father’s death. Simba also is punishing himself (by giving up his line to the throne) to relieve guilt
over his belief that his disobedience had caused his father to get trampled in a stampede.
17
Simba resumes normal development when Nala, his girlfriend, encourages him to save the pride from the hyenas
(sets an ego ideal); then, Simba’s father’s ghost admonishes Simba to do his duty (stimulates superego identification
with the lost object12). Simba’s aggression is not released from isolation, however, until his uncle, who had actually
caused Simba’s father’s death, admits this to Simba during a fight. Upon realizing he is not guilty of patricide, Simba’s guilt is relieved. No longer inhibited by guilt, Simba can now kill his uncle, save the kingdom, marry Nala and
give her a baby. His success neurosis is cured.
Up in the Air (2010) is a tragedy in which George Clooney’s brief transition to mental health is sadly fleeting. A traveling businessman who idealizes defensive emotional distancing as a lifestyle, Clooney’s value system is modified after
a female colleague chides him for avoiding a commitment with Vera Farmiga, with whom he has been having an affair. Finally, after object contact with his older sister, Clooney identifies with his sisters’ values, and drops the distancing in relationships. He is therefore shocked to find, on surprising Vera Farmiga at home, that she is married with
children. She was just using Clooney as an “escape,” i.e., a defense against loneliness when she was traveling. He then
defends against his disappointment by identifying with the aggressor—after the fact and regressing to more distancing.
Defenses and Psychiatric Diagnosis13
Defenses are rarely described in mental status examinations. Most psychiatrists mention deficits in functioning (such
as breaks in abstraction, integration, reality testing, and self-preservation), which often require medication. Problems
with sustaining close relationships, or “object relations” deficits are sometimes mentioned: weaknesses in capacities
for warmth, empathy, trust, and emotional closeness, and stability. These latter patients tend to need “relational”
work (Mitchell, 200014).
Also, defensive operations are frequently out of the range of people’s awareness. Most nonpsychotic patients complain of symptoms, unpleasant emotional states, and tangled relationship issues. They would like relief or advice. It
is quite uncommon for someone to complain of pathological defensive operations initially.
One method of locating unconscious defense involves noticing, as a therapist, when you want to ask a question.
There are two common reasons for this: 1) the patient is disorganized (integrative deficit)—which requires that you
structure the session; or more commonly, 2) the patient is using defenses. If people were not using defenses, you
would not need to ask them questions!
So when Jennifer, a 34-year-old depressed attorney, complains that her husband never listens, you want to ask,
“What do you ask him?” If she hasn’t already told you, likely there’s a defense. So you might say, “It’s interesting that
you’re kind of vague on the details there.” You may find that Jennifer had not given the details because she feels guilty
that she is so childishly demanding. A therapist who simply expresses understanding of how difficult it is to live with
a man who doesn’t listen, a seemingly empathic comment, may have a concordant identification (Racker15), and
thereby miss Jennifer’s unconscious conflict between oral demandingness and guilt, which led her to use projective
blaming as a defense in complaining about her husband.
Finally, we must consider defenses in pathological compromise formations.
Compromise Formations
Of the many rock bands that have recorded songs entitled, “Defense Mechanism,” State of Being has lyrics that are
the most astounding:
“…I have not resolved my internal abundance
of instinct drives motivation of fantasy
is punished by my social state
result of the conflict produces anxiety
formulating pressure into hate
neuroticism engulfs all...
defense mechanisms call...”16
It turns out that this is a fairly good description of the concept of compromise formation, first explained by Freud
(1926)17, codified by Waelder (1936)18, and refined by Brenner (2006).19 Compromise formations are the end results
of inner conflicts containing wishes (dependent, loving, and hostile-destructive); conscience reactions (guilt and
18
shame); perceptions of reality; affects; and defensive measures. The final resolution of these conflicts, when maladaptive, causes psychiatric symptoms and personality problems.
So why is John late to every meeting? After ruling out deficits in his reality testing or sense of time, we may find that
he wishes to be destructive toward authority, feels guilty about these wishes, hates boring meetings, defensively avoids
what he dislikes, and relieves his guilt by getting himself punished. Thus we have one common compromise formation found in the procrastinator.
John may also express his wish to be lazy at the same time he gets himself humiliated to relieve shame. In addition,
the work group may be symbolic of John’s adolescence, and his lateness represents rebellious/self-punishing reactions he had to his father as a teen (“transference” to the group).
If someone just tells John to be on time (a logical first step), it may inflame his procrastination because of the transferences, conflicts, and defensive operations. If so, John will then need an interpretive approach, where the therapist
explains how John’s compromise formations are tripping him up. Considering that John can use abstract thinking,
he should be able to understand the symbolism of what he is doing. With an intact integrative function, he should be
able to make use of his new understandings to reintegrate, and stop “acting out” his conflicts.
A Brief History of Defense
Defense theory was originated, not surprisingly, by Sigmund Freud (189420). By 190021, Freud named this activity
“the censor,” and by 192322, “repression,” which seems to have lasted. Anna Freud made the first list of defenses in
193623. In 1982, Brenner clarified that anything can be used as a defense.
The Electrified Mind (Akhtar, 201124) contains many chapters regarding autistic defenses used by teenagers to avoid
painful feelings; they can get lost on the internet in such sites as “Second Life,” and “World of Warcraft.”25
Using Defense Theory in Conjunction with Other Therapeutic Approaches
When people are anxious or depressed, there are a variety of efficacious therapeutic approaches, including medication, cognitive-behavioral therapy, and dynamic (interpretive) therapy. The set of indications for each, and the exact
techniques utilized, are matters of ongoing study and discussion.
Sometimes different therapeutic approaches can be used effectively in combination. Sarwer-Foner26 published a
textbook about the symbolic implications of medication.27 In recent years, it has become common for psychoanalysts
to prescribe (or refer patients for) medication.28 In addition, some cognitive-behavioral therapists have integrated
dynamic techniques, such as exploring why patients (defensively) “forget” to do homework.
Blatt29 (1992) described defensive causes of depressive affect, such as avoidance of mourning over losses (Volkan30,
1987), or turning anger on the self (Menninger31, 1933) to avoid guilt. If a patient has enough abstraction, integration,
reality testing, and self-preservation, interpretation of defenses and conflicts is usually therapeutic.
Ironically, as defense theory has been refined32, some psychoanalysts have sidelined the concept, focusing instead on
“attachment”33—how the therapist interacts with the person requesting help.1
Some Parting Thoughts
The concept of defense starts with the common-sense observation that most people tend to avoid things that are
unpleasant unless they, for some reason, cannot do so. We then define defense as a sort of circuit breaker used to
guard against unpleasurable affects associated with reality or with unconscious inner conflict. Defenses shut mental
contents out of consciousness. When those contents are stored in memory, they can often be retrieved, along with
the previously unconscious defenses, during interpretive therapy.
Defenses, although present in severe mental illnesses (psychoses and near-psychoses34), are not the cause of such disturbances, and interpretation of them is generally not part of the treatment approach. Defense theory, on the other
hand, facilitates diagnosis of people who do not show much deficit in basic mental functions, where highlighting
defenses is generally used to help them rethink their problems and reorganize their thoughts and actions.
___________________________
1
Blackman, J. (2010)
19
REFERENCES
Tillis, Pam. (1997). Queen of Denial. http://music.barnesandnoble.com/Queen-of-Denial/Pam-Tillis/e/723721412456
(accessed January 9, 2011)
2
Schwartz, A. (2008). Denial of Addiction: A Serious Problem. Alcohol and Substance Abuse.
http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=28976 [accessed January 9, 2011]
3
Big Brothers merged with Big Sisters in 1977.
http://www.bbbs.org/site/c.9iILI3NGKhK6F/b.5962335/k.BE16/Home.htm (accessed January 2011).
4
These and other defensive operations are defined, with clinical examples in Blackman, J. (2003). See below.
5
Barry, D. (2010). I’ll Mature When I’m Dead: Dave Barry’s Amazing Tales of Adulthood. New York: G.P. Putnam’s Sons.
6
Brenner, C. (1982). The Mind in Conflict. New York: International Universities Press.
7
Berlin, H. and Kock, C. (April 13, 2009). Defense Mechanisms: Neuroscience meets Psychoanalysis. Scientific American http://
www.scientificamerican.com/article.cfm?id=neuroscience-meets-psychoanalysis (accessed January 2011).
8
Baddeley, A. Eysenck, M., and Anderson, M. (2009). Memory. New York: Taylor and Francis, Inc.
9
Solms, K. & Solms, M. (2001). Clinical Studies in Neuro-Psychoanalysis: An Introduction to a Depth Neuropsychology.
London: Karnac Books.
10
Reiser, M. (1999). The New neuropsychology of sleep. Neuropsychoanalysis 1:201-206.
11
(2008) Personal communication.
12 Sandler, J. (1960). On the concept superego. Psychoanalytic Study of the Child 15: 128-62.
13
Blackman, J. (2010). Get the Diagnosis Right: Assessment and Treatment Selection for Mental Disorders.
New York: Routledge.
14 Mitchell, S. (2000). Juggling paradoxes: commentary on the work of Jessica Benjamin. Studies in Gender and
Sexuality 1: (3) 251-269
15 Racker, H. (1953). A contribution to the problem of countertransference. International Journal of Psychoanalysis 34:313-324.
16
http://www.elyrics.net/read/s/state-of-being-lyrics/defense-mechanism-lyrics.html (accessed January 2011).
17 Freud, S. (1926). Inhibitions, Symptoms, and Anxiety. Standard Edition 20: 75-176.
18 Waelder, R. (1936). The principle of multiple function: observations on overdetermination. Psychoanalytic Quarterly 5: 45-62.
19
Brenner, C. (2006). Psychoanalysis: Mind and Meaning. New York: The Psychoanalytic Quarterly.
20 Freud, S. (1894). The neuro-psychoses of defense. Standard Edition 3: 41-61.
21
Freud, S. (1900). The Interpretation of Dreams. Standard Edition 4: ix-627.
22
Freud, S. (1923). The Ego and the Id. Standard Edition 19: 1-66
23
Freud, A. (1936). The Ego and the Mechanisms of Defense. New York: International Universities Press.
24
Akhtar, S., Ed. (February 2011). The Electrified Mind: Development, Psychopathology, and Treatment in the Era of Cell Phones and the Internet. New York: Rowman and Littlefield Publishers, Inc.
25
Blackman, J. (2011). Separation, Sex, Superego, and Skype. In: The Electrified Mind: Development, Psychopathology,
and Treatment in the Era of Cell Phones and the Internet. Ed: Akhtar, S. New York: Rowman and Littlefield
Publishers, Inc.
26
Sarwer-Foner, G. (1960). The Dynamics of Psychiatric Drug Therapy. Springfield, IL: Charles Thomas.
27
Sarwer-Foner, G. (1989). The psychodynamic action of psychopharmacologic drugs and the target symptom
versus the anti-psychotic approach to psychopharmacologic therapy: thirty years later. Psychiatry Journal of the
University of Ottawa. 14(1): 268-7.
28
Normand, W. & Bluestone, H. (1986). The use of pharmacotherapy in psychoanalytic treatment. Contemporary Psychoanalysis 22:218-234.
29
Blatt, S. (1992). The differential effect of psychotherapy and psychoanalysis with anaclitic and introjective patients:
The Menninger Psychotherapy Project Revisited. Journal of the American Psychoanalytic Association 40:691-724.
30
Volkan, V. (1987). Linking Objects and Linking Phenomena. New York: International Universities Press.
31
Menninger, K. (1933). Psychoanalytic aspects of suicide. International journal of Psychoanalysis 14:376-90.
32
Abend, S., Porder, M., and Willick, M. (1983). Borderline Patients: Psychoanalytic Perspectives. New York: International
Universities Press.
33
Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology
28:759-775.
34
Marcus, E. (2003). Psychosis and Near Psychosis: Ego Function, Symbol Structure, Treatment. (Revised Second Edition).
Madison, CT: International Universities Press.
1
About the Author:
Dr. Blackman has authored several books, including 101 Defenses: How the Mind Shields Itself (Routledge, 2003), which has been
translated into Chinese, Romanian, and Turkish. He is a Professor of Clinical Psychiatry at Eastern Virginia Medical School in
Norfolk, Virginia, and a Training and Supervising Analyst with the Contemporary Freudian Society Psychoanalytic Training
Institute in Washington, D.C. He is a Distinguished Fellow of the American Psychiatric Association, and Fellow of the American
College of Psychoanalysts. He is in private practice of psychiatry and psychoanalysis in Virginia Beach, VA, USA.
Website: http://jeromeblackmanmd.com. Correspondence is welcome at [email protected].
20
There is More to the Story:
CLINICAL EXPERIENCE
WITH TMS
By Gary Spivack, M.D.
Transcranial Magnetic Stimulation (TMS) refers to a technique for treating depression by focusing a magnetic field
on an underactive part of the brain to stimulate its neurons to fire. It has been FDA approved for use in adults 21
years and older who have Major Depression and who have failed one adequate trial of an antidepressant. Clinically, it
has been used off label to treat a variety of conditions —depression other than Major Depression, i.e. Bipolar Disorder and Mood Disorder, NOS, as well as anxiety disorders and pain disorders, much like many psychiatric medications such as Cymbalta and other antidepressant medications.
Essentially, the theory behind TMS is that there are underactive areas of the brain in depression, e.g. the prefrontal
cortex, and that if these areas can be appropriately stimulated then the cycle of depression can be broken. Antidepressants target this chemically through effects on neurotransmission mostly around the neural synapse. These
effects however are throughout the brain and the entire body resulting in many unwanted side effects. TMS directly
stimulates neurons to discharge and fire and involves only those areas of the brain that are specifically targeted. This
accounts for its negligible side effect profile.
The physics of TMS is based on the fact that a conductor placed in a magnetic field will result in an electric current
being generated. The brain is a conductor and the magnet in the TMS machine provides the magnetic field. It does
require a powerful magnet equivalent to the one used in an MRI machine. The next key element is that the magnetic
field must be able to be focused on a particular area of the brain. The shape of the TMS coil allows the prefrontal
cortex to be targeted.
The first TMS session is called the “brain mapping session.” The anatomy of each person’s skull and brain varies
enough such that we cannot rely upon anatomical markings of the skull to properly target the prefrontal cortex.
21
Fortunately, we are able to find the precise location of the area of the motor cortex that controls the thumb and first
finger and this orients us accurately in the treatment. We use single pulses to stimulate this area that is verified by
virtue of the thumb and forefinger twitching. We then target the area in front of this by 5.5 cm.
Although TMS is indicated when just one adequate trial of an antidepressant has failed, most patients referred have
had multiple trials of many different antidepressants, mood stabilizers, etc. over many years along with years of psychotherapy and many have also had ECT. We have primarily treated the most treatment-resistant patients with TMS.
We expected that our results would have been worse than the 35% or so response rate seen in trials of TMS used as
mono-therapy in patients who failed only one antidepressant. However, as with most situations involving human
beings: THERE IS MORE TO THE STORY.
Patients generally do not reach our doors with uncomplicated depression that responds easily and well to an antidepressant. There are usually several layers of complicating factors that are interwoven and that lead to vicious
cycles from which escape appears impossible. There are often real losses—death, divorce, and geographic moves that
have broken social ties—as well as alcohol, drug and medication misuse and abuse. One common scenario involves
overwhelming grief that has provoked a depressive episode resulting in drug use, dropping out of school or quitting
a job, with further loss of positive social interactions.
Our approach to the use of TMS has been to focus on the person who has the treatment resistant depression and to
use TMS as part of the whole solution to the treatment resistance. We start with a comprehensive evaluation in an
effort to understand the entire biopsychosocial underpinnings of the person’s depression and the whole history of
the treatment and the lack of response. We then seek multiple points of intervention.
Several case examples will illustrate this pattern. I will then return to some crucial theoretical underpinnings that
may explain why our success rate with TMS has been so high. I have borrowed some material from Dr. Robert Post
(with his permission) and who performed some of the seminal research on TMS at NIMH. Dr. Post co-presented
with me at the Spring Symposium.
Case 1
Mrs. X called to ask about TMS and set up an appointment for her daughter, Mary, who was living at home and attending a local university after having withdrawn on medical leave from a top ten university. Mary came to the first
appointment herself. Mary talked about having just stopped her therapy with her psychiatrist over a dispute around
stopping daily marijuana use. The treatment was at an impasse, yet she wanted to get better.
She was stuck in grief over her brother’s death three years earlier. She has lost weight due to diminished appetite. She
had been treated most recently with an antipsychotic and tricyclic and took sertraline and other SSRIs in the past.
She wanted relief from her depression in order to be able to stop smoking marijuana. The diagnosis was MDD, Grief
Reaction, and Marijuana Abuse. She also had IBS and migraine headaches. Our strategy was to use the TMS to give
relief of depressive symptoms while we worked with her in psychotherapy to enable the grieving process. Over the
course of eight weeks, she completely stopped all drug use, she was able to grieve the death of her brother, she kicked
out her drug-abusing boyfriend who had been living with her, and she planned to return to school. Six months later
she returned to her top ten university.
Case 2
Carmen, a 21 y/o female, is a senior in high school and living with her divorced mother. A pain medicine clinic
referred her for treatment of severe depression. She was suicidal in part because of intractable pain. She was first
treated on an inpatient unit and received TMS in a partial hospital program. She was hospitalized five times the past
year, mostly for suicidal ideation and urges that had become overwhelming. I had treated her younger brother for
a severe mood disorder. She could not enroll in a pain rehab program until her depression was more stable but her
depression would not improve until the pain eased. Suicidality got worse on antidepressants, which were also used to
treat her severe pain. She was regressed to the point of sleeping in her mother’s bed.
She had difficulty at first tolerating the TMS due to local scalp discomfort as the magnet pulsed. The power of the
pulse had to be diminished and was then gradually increased. Several sessions also had to be interrupted because of
vomiting from her IBS or she did show up due to her migraine headaches. However as the treatment progressed her
22
mood became euthymic for the first time in years along with a marked decrease in pain and need for pain medication. She began to make plans to go out with friends and she began to look forward to college. She moved back into
her own bedroom, was able to be discharged from PHP, and she followed physical therapy rehab for her fibromyalgia
that allowed her to lose weight.
Case 3
Mrs. Z called about her 19 year old daughter who had dropped out of the religious-affiliated school that she loved
both appeared together for the consultation. Her daughter had a history of intense anxiety beginning in the 5th
grade and ADD was diagnosed in the 9th grade along with the onset of sever depressions. In the past year she also
experienced the onset of mania. The patient had been diagnosed with IBS and fibromyalgia and was taking several
medications for pain including Lyrica (which caused a 50 lb. weight gain) and high dose Tylenol. She was on Topamax for migraine prevention. She had been treated with medications for many years by the same psychiatrist and
she was in psychotherapy with a social worker.
When she was referred to us, she had been on multiple medications and she was taking a mood stabilizer, an antipsychotic medication, an antidepressant, Deplin, etc. She became hyper-religious when manic. She felt that a male
peer stalked her. She loved her experience at this school and felt that leaving it was an irreparable loss. Her father,
who also had bipolar disorder, had recently died, as did her grandfather to whom she was also close. Her mother had
made several suicide attempts. Following a course of TMS this young woman achieved a total remission that included her ability to use her high IQ at a new university. Her mother was so impressed by the results that she wanted
TMS for her own depression. Interestingly, the mother’s results were just as good. She got back to her own very high
level of occupational functioning.
Each of the above patients had extensive prior treatments involving both psychotherapy and medication—yet was
unable to emerge from the severe depression they were experiencing. We believe that TMS played a dual role in helping them achieve remission through its direct effect on the depressive symptoms themselves and by opening up a
reconsolidation window that allowed the psychotherapy to be more effective.
Traditional theory holds that once a memory has been consolidated, i.e., placed into long-term storage, it exists as a
permanent trace. According to this view, the most one can hope for therapeutically would be to inhibit the memory’s
expression through a mechanism such as extinction, but this inhibition is fragile, and the associated distress and
arousal may return.
Ample evidence suggests that reactivating a consolidated memory returns it to a labile state, during which the
memory is again susceptible to interference. This window of opportunity appears to open shortly after reactivation
and to close approximately six hours later although this may vary depending on the strength and age of the memory.
By allowing new information to become incorporated into the original memory trace, this memory may be updated
as it reconsolidates.
We believe that the inability to rework key memories underlies some of the treatment resistance and that delivering
psychotherapy during the TMS procedure opens a reconsolidation window that allows the memories to be altered
by the therapy. This results in the patients being able to make progress in areas of their lives that were dysfunctional
and that maintained the depression. The crucial point is that when memories are recalled, there is a short window of
time during which they can be altered and TMS may enhance this process. Essentially, we are enhancing the efficacy
of therapeutic interventions by pairing TMS temporally with the psychotherapeutic intervention.
I do not underestimate the effect of the intense interpersonal connections formed during the treatment between the
patients and our psychiatric nurses who administer the TMS and provide the psychotherapeutic interactions. Not
surprisingly, for such an intense treatment, we have also had to carefully manage many transferential and countertransferential issues that have arisen during the TMS treatment. We have had several surprising scenarios in which
patients have been able to grieve losses that had bedeviled them for years, to stop massive illegal drug use, and to give
up addictive self-injurious behaviors such as cutting and burning.
Our experience has shown us that TMS, through its direct effect upon depression and its ability to open the reconsolidation window, offers new hope to a whole group of patients for whom current treatment options have not
worked. But it is best employed as part of an intensive treatment program based on the overall biopsychosocial needs
of the patient because when it comes to treating human beings, THERE IS MORE TO THE STORY.
23
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The Psychiatrist in the Security Clearance Process

Transcription

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