Archive for October, 2009
What I Learned Part 1
Here's a brief summary of tidbits from the first day of the American
Academy of Psychiatry and Law conference.
First, there was an interesting keynote by Dr. Pat Recupero regarding
how to incorporate questions about the use of the Internet into the
mental status examination and the ethics of googling patients. (Shrink
Rap reader?)
The Indiana v Edwards case is a popular topic for presentation.
Defendants who represent themselves at trial are more likely to be
convicted of misdemeanors than felonies. Lots of discussion about how
pro se competence should be assessed and what the standard should be.
Got to meet and listen to Dr. Steve Morse, doing some of the most
fascinating research in forensic neuroscience. He stated functional
MRI will likely never be determinative of any legal issue. Favorite
quote: "Brains don't kill people, people kill people." Followed by:
"The only thing we know for sure about the mind and the brain is that
when the brain is dead, the mind is gone."
Six Federal jurisdictions have case law to bar third party observers
(ie lawyers) from forensic evaluations.
There are still people writing books about ritual cult abuse. They are
still not acknowledging that some claims may not be true, not even
after multimillion dollar malpractice actions for implantation of
false memories and exoneration of alleged perpetrators.
There was a presentation about expert witnesses' transference
reactions to attorneys and defendants. I think this is a pretty broad
stretch of the term.
Interesting historical overview of multiple personality disorder. The
patient Sybil had her sessions recorded. Her psychiatrist, Dr. Wilbur,
can be heard invoking and assigning names to her alters. The patient
Eve, Chris Sizemore, later wrote an autobiography repudiating her
diagnosis. Fifty-seven percent of audience (forensic psychiatrists)
did not believe in the disorder. Fifteen percent of surveyed general
psychiatrists think dissociative identity disorder should be removed
from the DSM. There was discussion of the role of the media and the
book Courage to Heal in precipitating the DID epidemic. DID experts
themselves disagree about the literal reality of satanic ritual abuse.
Some say this is a metaphor for severe psychological trauma. The FBI
division for offenses against children has never found evidence of
such cults.
Burgus v Braun is a landmark case for anyone working with trauma
patients. It resulted in a 10.3 million dollar settlement against
therapists for malpractice and Dr. Braun was expelled from the APA.
Posted in The Goat Story
There are some tales that will only live in infamy, to be told only after generations have passed…
Sent from my iPod
AstraZeneca To Pay Feds $520 Million To Settle Seroquel Claims
Just out this morning in AZ’s third quarter financial results is this little whopper:
“Agreement in principle reached with the US Attorney`s Office in Philadelphia to resolve its investigations related to Seroquel sales and marketing practices. This accounts for $520 million of the $538 million provisions taken in the first nine months, $108 million of which taken in third quarter.”
I don’t have any more details on this yet, so stay tuned.
Excepting J&J/Janssen, all the makers of atypicals have agreed to settlements with the feds over illegal marketing.
Pristiq Ad Runs During World Series As Adverse Events Reports Mount
Yes, that creepy ad for Pristiq with the woman staring at the wind-up doll has been running again during the ALCS and NLCS and now during game one of the World Series last night (won by the Phillies 6-1 over the Yanks with a big assist from former Mariner Raul Ibanez). It’s bad enough having to sit through Cialis and Viagra ads during the Fall Classic, but anti-depressant ads, too? Hand me a beer instead. You see the ad here.
Meanwhile, adverse events for the Son of Effexor continue to mount and stand at 1,361 adverse events reports in the FDA’s database. That’s good going for a drug that’s been on the market two-plus years and that still is used so little that Pfizer (Wyeth’s new owner) doesn’t list third quarter 2009 sales figures for the drug.
Congress To Go After Medicaid Fraud, Why Not Fraud Against Patients Too?
The Wall Street Journal noted yesterday that Congress is planning to take steps to wipe out the estimated $60 billion a year in Medicaid fraud.
“‘The scale of health care fraud in America today is staggering,’ Senate Judiciary Committee Chairman Patrick Leahy (D., Vt.) said at a hearing. ‘Now, as health care reform moves through the Senate, I want to make sure we do all we can to tackle the fraud that could undermine efforts to reduce the skyrocketing cost of health care.’”
That’s all well and good and I wish Congress luck. A good amount of the fraudulent behavior comes from our friends at America’s Pharmaceutical Research Companies (see Lilly, Pfizer, BMS, etc.). All of the billions in awards the feds have gotten out of these companies for ripping off taxpayers has also come at the expense of individual Americans who, in many cases, never get compensated and never get the satisfaction of watching a Lilly exec, say, do a perp walk. Meanwhile, their bodies are ravaged.
Congress ought to be interested in beefing up consumer protections regarding pharmaceuticals and also in creating penalties that really matter instead of the situation we have now where pharma basically pays off the feds through its liability insurance. The system of laws and regulations in place now is apparently not sufficient to protect Americans against another Zyprexa or Byetta.
Yes, I Got Spoofed
JC, a reader from Back East somewhere, left a comment yesterday that I broke out as a post because he fooled me into thinking he really was one of the Biederman groupies, bipolar child defenders, etc. His comment was so perfect that it got by my BS detector, which may not have been fully on at 10.30 am. It’s classic and you all should go read it here.
What I love is that JC says he took a lot of the language straight from the Child and Adolescent Bipolar Foundation website.
Weirdest Comment Ever On This Site
And thus well worth highlighting since it comes in response to the JAMA study which found that antipsychotics are putting tons of fat on youngsters.
“I think this report smells fishy. Smells like the work of anti-psychiatry Scientologists. Psychiatric medications are a healthy part of a balanced lifestyle for the majority of children with childhood bipolar disease, a serious but treatable medical condition.
“My child has bipolar disorder and I’ve come to learn that her rages have nothing to do with me and that this is a highly genetic biological brain-based disorder.
“We have her on eight meds prescribed by the director of our local university clinic and we’ve received extensive psychoeducation about the nature of her disease. Additionally, my husband and I attend a support group three times a week for parents of bipolar children at the hospital.
“I trust very much in the power of medicine and am very thankful for the big glitzy university hospital where we live. Her neuropsychopharm says that when taken as prescribed, her medicines including the atypicals are safe and effective. They’re all FDA approved drugs anyway.
“Studies like this are done by stupid Scientologists that don’t understand brain-based disorders.”
Speaks for itself.
Harvard Psychiatrist Stabbed, Patient/Attacker Killed
Yesterday, a tragedy occurred at one of Massachusetts General’s buildings. A patient attacked a psychiatrist named Astrid Desrosiers with a knife, reportedly inside the Massachusetts General Hospital Bipolar Clinic & Research Program. An off-duty security guard shot and killed her assailant, identified as Jay Carciero, after he refused to surrender and put down his knife. Desrosiers is reportedly is serious, but stable condition. I wish her a continued and speedy recovery.
I’m sure we’ll learn more about this tragedy in the near future.
JAMA Study Slaughters Antipsychotics For Kids, Teens Paradigm
Late yesterday I got a copy of the JAMA study detailing how kids and teens on atypical antipsychotics are putting on lots of weight very quickly and suffering detriments on just about every metabolic measure researchers looked at (my initial post is here). I’ll come to the study itself in a moment as well as the accompanying editorial, but first I wanted to note that I have been banging on the kids-on-meds issue (especially atypicals) for three years and have taken a ton of heat in the process. I feel vindicated by this new study and other recent studies tossing cold water on various treatment paradigms involving kids and many of you should feel vindicated as well. I remember how gingerly I first took on the subject in November 2006 and how many of you kicked me in the pants and told me to trust my instincts. Thanks.
The Drama Triangle: Victims, Rescuers and Persecutors
Sometimes called the Karpman Drama Triangle, this is a powerful script which some clients find themselves locked into. The triangle has three roles: Victim, Rescuer and Persecutor. These three roles work to form a cycle of blame and guilt which allows all three “players” to avoid taking responsibility for their own emotions, beliefs or behavior.
The function of this particular “game” is to direct the players’ attention away from their own faults and onto others’. It also works to distract the players from taking responsibility for their own needs and behaviors and speaking the truth about what is actually going on. Their energies are instead redirected into blaming, defending and rescuing. The greater the intensity of the game the more the players are avoiding being responsible for the truth of what is really going on. Players of the game unconsciously thrive on the drama involved and prefer it to the boredom of reality or the responsibility of owning their own emotions or actions. It’s much more interesting to blame someone else and denial is powerful in this game. If you don’t believe it, watch what happens when one of the players suggests that everyone be responsible for themselves. Panic will ensue. Attacking, blaming, guilt and manipulation with quickly escalate. Most of the players think they have the upper hand in the game and don’t realize that each player pays a price for maintaining their role.
The three roles of this triangle are:
The Victim – “Help me”, “Poor me”, “Damsel in distress”
Victims harbor a belief that they are unable to care for themselves. They feed the self esteem needs of a Rescuer by telling them how much they need and appreciate them in order to keep the Rescuer taking care of them. Victims feel victimized, oppressed, hopeless, helpless and ashamed. They often complain of depression or appear depressed due to the apparent hopelessness and helplessness of their position. They deny responsibility for their lives and deny having the power to change them. Being the Victim allows them to deny responsibility for failure or avoid even trying.
Everyone needs support at certain times in their life. But Victims make a lifestyle of it. It can become their identity. They may base their claim to needing help on being too weak, too sick, too insane, or not smart enough. They use their dependence to keep people (Rescuers and sometimes Persecutors) tied to them. They are masters at providing the appreciation and gratitude that Rescuers crave, but then resent having to give it and resent the Rescuer for taking it. This resentment builds until they blatantly sabotage the Rescuer’s efforts then blame the Rescuer for the failure, switching to the Persecutor role. More skilled Victims will employ passive aggressive behavior to sabotage the Rescuer’s efforts. One of their favorite games is, “Yes, but…” They agree whole heartedly agree with every solution the Rescuer presents, but counter with a reason why they can’t do that. It is crucial that the Rescuer’s efforts fail else the Victim be empowered and lose the Victim role. The Rescuer often goes along for the same reason. If the Victim gets up and walks away the Rescuer is no longer needed. So they remain locked in this dance, each taking turns as Persecutor, blaming the other for their alleged failure.
Victims are often taken to therapy by Rescuers as the “identified patient” to be fixed by the therapist. An unenlightened therapist might take on this challenge and ultimately become the temporary third point in the triangle, caught up in a powerful dynamic before they realize what has happened.
Victims also feed off the Persecutor. A good Persecutor is invaluable to a Victim because it further elucidates their Victim status to everyone who observes the Persecutor “abusing” the Victim. Persecutors can be individuals or institutions. Victims may complain that the Child Protective Services system, the legal system, the IRS, the mental health system or the medical system is “persecuting” them by holding them responsible for their behaviors or by failing to provide them the care they think they deserve.
Victims may falsely accuse Rescuers of abuse or maltreatment in order to increase their Victim status in the eyes of others. They may accuse a spouse of battery which has not occurred. An elderly Victim may falsely accuse the child taking care of them of neglect. An adult Victim may accuse an elderly parent of favoring one of their siblings if the parent doesn’t give in to their desires or wishes. Victims may even make false reports to the police, Child Protective Services, Adult Protective Services, the family pastor or a medical doctor. These false accusations are made to garner sympathy from third parties.
The price paid by the Victim for being cared for is often feelings of depression as a result of the helplessness and hopelessness which much be perpetuated to maintain the role. Dependency is another price which can be quite high if the Victim spends a lifetime not learning to be responsible for themselves and makes themselves dependent on an elderly parent who eventually passes away. The Victim is then left at a mature age with no coping skills except to try to enlist another Rescuer into taking care of them.
Rescuer - “Let me help you”, “Hero”, “Good guy/gal”
The Rescuer often believes that their own needs are not important and that they are subjugating their own needs for those of others. They believe that their only value is through helping others. You often see Rescuers in the roles of social worker, nurse, political activist and unfortunately, if they haven’t worked through their issues, therapist. When a Rescuer subjugates their own needs in excess of their capabilities you will see burnout and resentment toward those they are rescuing. Whether it is the child taking care of a dependent parent who gets fed up or a social worker who gives too much of herself and develops burnout and frustration with the population she is committed to serving, the results are often attacking or blaming those they are trying to help (Persecutor) or martyrdom (Victim).
Rescuers often feel manipulated, used and unappreciated by those they are rescuing. They may move from Rescuer to Persecutor as a result of these feelings but rarely see themselves as Victim. They may play the martyr card when these feelings emerge and can be heard saying, “After all I’ve done for you…”, “Nothing I do is ever enough”, or “Nobody appreciates me”. They often enter into relationships where they are needed hoping that the other person’s dependence on them will bind them to the Rescuer and prevent the Rescuer from being abandoned.
Most Rescuers have no idea how enabling and infantilizing they are to those they “save”. Most see themselves as totally selfless and full of good intentions and indeed some of their works result in good outcomes. But that is not the complete picture. There is a huge payout in being a Rescuer. The very act of rescuing feeds one’s ego and is a feel good tactic to nurture their own low self esteem. They rescue in order to increase their own feelings of self worth, to increase their power over others, to guilt, to smother, or to control others “for their own good”. They may get riled up by the Persecutor and turn on the Victim.
No matter how much they think the Victim may need their help, rescuing someone else can only create a Victim. There is a marked difference between being a Rescuer and being a person who supports and nurtures another person. A Rescuer sees the other person as a Victim who is helpless and incompetent and in need of the Rescuers skills in order to survive. A true helper sees the other person as a survivor who has the intelligence and strength to get through this but could use some support or a shoulder to cry on now and again. The Rescuer likes to control the support in the Drama Triangle interaction. In a healthy interaction the person in need is in control and a true helper is merely a supportive role. A Rescuer maintains a dominant position in the relationship and infantilizes the Victim by keeping the power and responsibility for themselves. A true helper empower the person in need of assistance to overcome the difficulty themselves. A Rescuer “helps” by controlling, deciding and leading. A true helper “helps” by letting the client lead, letting the client make their own choices and leaving the client in control of the situation.
The Rescuer has a lot to gain from this interaction. They are usually viewed as a “good person” and given kudos from family, friends and community for so “selflessly” giving of themselves to help others. But it comes at the cost of their own feelings, thoughts and actions. They consistently subjugate their own needs for those of others and do not learn to stand up for and ask directly for what they need. They are often overworked and tired. And they don’t really help people. Truly helping people allows the person you helped to get up and walk away from you. This is not what Rescuers do. They “help” the person by keeping them helpless and dependent on the Rescuer which the Rescuer usually ends us resenting.
Persecutor – “It’s all your fault”, “Villain”, “Bad guy”
Persecutors typically blame the Victims for being dependent and blame the Rescuers for enabling. They do this without providing any constructive solutions to the problem.
Victims may adopt the role of Persecutor if they perceive they are not receiving the protection or rescuing they think they deserve. They may Persecute a Rescuer they feel has failed them. They may also be a Rescuer who is feeling unappreciated or manipulated by a Victim and resorts to Persecuting the Victim for being so needy or unappreciative of their efforts. Persecutors can also be traumatized people who see the world as a very dangerous place and who feel the need to strike first before others can strike at them.
The Persecutor role often originates in shame. They feel and fear their own inadequacies and build themselves up by tearing others down. They compensate for their own flaws by focusing on those of others. They often try to reform others by guilt, shame or force. Both Rescuers and Persecutors need a Victim in order to feel superior. Persecutors literally “blame the victim” by saying things like, “they deserved it” or “that’s what you get”.
Some Persecutors can play out the game in any number of ways including constant legal battles, religious self-righteousness and even physical assaults. Persecutors typically have a strong external locus of control, blaming everyone else for their problems and going through life angry at the world. They have a strong sense of what is “just”, “fair” and “right” and punish those who they perceive are in violation of these universal (according to them) values.
Persecutors are often Scapegoats, though Scapegoats can revert to the Victim role (”look how badly I’m treated”) or Rescuer (”I’ll save everyone to prove to them that I’m really a good person”).
Victims and Rescuers trying to leave the triangle may be viewed as Persecutors. Victims may guilt an exiting Rescuer with some version of “how can you stop taking care of me?” and Rescuers may guilt existing Victims with some version of “how can you no longer need my help?” Both may be perceived as Persecutors by those who remain in the game.
The only way for a Persecutor to get out of this triangle is to take responsibility for their own behavior. They have to stop to external focus on everyone else’s behavior and look at their own. They have to stop attacking and blaming and work on changing themselves instead of others.
The payoffs for the Persecutor is being able to deny their own inadequacies by focusing on everyone else’s. They are very good at keeping the drama going because they will go to the Victim and complain about how the Rescuer treats her like a child and looks down on her, instigating a conflict between the Victim and the Rescuer. Or they will go to the Rescuer and complain about helpless and needy and unappreciative the Victim is toward the Rescuer and start a fight that way. Their favorite game is, “Let’s You and Him Fight”. By keeping the drama going they are able to deny and distract from their own flaws and foibles. The price they pay is in being agitated, incensed and angry all the time which is a difficult way to go through life. It may cause them to be alienated in relationships and in work situations because people get tired of someone who is always so negative. It also keeps them from owning their softer, more vulnerable side. They are not a complete person. All of their energy is dedicated to being outraged, which tires them and keeps others at a distance. This negative energy also draws other Persecutors, complainers and blamers to them so they are swimming in a constant sea of negativity.
The Game
The interesting thing about this script is that the roles can be so fluid. Sometimes the roles are solidly locked and people are heavily invested in staying in the assigned role at all cost. But most of the time participants in this script rotate through the roles so fluidly and effortlessly that they don’t even realize they are changing roles. In fact, this entire process is largely subconscious. One day they are the Victim, the next the Persecutor, then the Rescuer. People don’t get up in the morning and announce, “I’m going to be the Persecutor today!” The process is so very subconscious that most people aren’t even aware they are dancing to this tune.
Even therapists get sucked into this game quite frequently, usually as the Rescuer. A client will present in the Victim role asking for help with a problem. Let’s say depression. She will turn to the therapist to “save” her. If the therapist has not done her own work she may jump at the chance to be the “hero” and “save” the client, taking up the role of Rescuer. They may work together several months with the therapist making helpful suggestions about what the client can do to alleviate her depression. The client never quite follows the suggestions and no improvement is made. The client may then slide into the role of Persecutor, blaming the therapist for the failure to reduce her depressive symptoms. The therapist may slide into the Victim role, “Look at all I’ve done for you and you don’t appreciate it!” or take over the Persecutor role, blaming the client for the therapeutic failure.
Families are often the origin of this game. A family with substance abuse issues can be the perfect context for this particular game. Perhaps the substance of choice is alcohol. The alcoholic will be the Victim who is enabled by the Rescuer until the Rescuer plays the “look at all I’ve done for you” card when the Victim will flip and become the Persecutor, “if it weren’t for you I wouldn’t need to drink.”
The game is usually learned in childhood. If the child is a drug addict (Victim), constantly taken care of by an enabling parent (Rescuer) they often grow up to be adults who expect their partners, spouses and other people to take care of them as well. When other adults fail to play Rescuer the drug addict may move from Victim to Persecutor, resenting those who don’t save him.
The only way to move out of the triangle is to become aware of the game and stop acting out the roles. Like any other role you might be locked into, if you stop playing it the other members of the game may increase their pressure upon you to re-engage in the role. Pressure tactics may include guilt, manipulation, lies and the “ganging up” on you by several family members. This is where good boundary maintenance becomes crucial.
Another interesting thing about this script is the power. Power in this drama doesn’t necessary reside where you think it might. You would think the Persecutor or the Rescuer might have the upper hand, but I also see Victims who are running the entire show by guilting or manipulating the Rescuer to take care of their every need or the Persecutor to keep up their attacks and therefore draw sympathy for them as a Victim. Often the Victim vacillates back and forth between the Victim role and the Persecutor role in order to keep the Rescuer busy taking care of them. Of course being locked in the Victim is a prison of its own.
Notice also that no one in this game is maintaining good self care or boundaries. Every move that is made is about someone else’s feelings or needs. They are all feeding off each other. The Rescuer gets appreciation from the Victim, the Victim gets support from the Rescuer, the Persecutor gets to blame both. No one is taking care of their own needs. And the system is rife with guilt, manipulation, infantilizing, enabling, resentment, blaming, shaming and gaming. These are not honest, open interactions. Nor is the support they glean from each other free or healthy. The Victim must grovel for help. The Rescuer must give up their own needs to meet those of the Victim’s. The Persecutor is making themself feel better by blaming everyone else and not taking responsibility for their own behaviors. The Victim and Rescuer may suppress a lot of their thoughts, emotions and beliefs in order to stay in the game with the other. The Persecutor may give up a lot of her “softer” emotions and vulnerability in order to maintain the role of Persecutor.
Leaving the Game
The secret to leaving the game is first to:
1. Be aware that the game is occurring
The first step is always awareness and education. You have to know you are doing something before you can do anything about it. Examine your beliefs. Do you consistently view others as being helpless (Victim), hostile (Persecutor), or martyred (Rescuer)? Examine your behavior. Do you tend to egg other people on to blame or attack a third party? Do you allow yourself to be sucked into attacking others? Do you absorb other people’s anger or blame? Do you fight other people’s battles? If so, you might be involved in a drama triangle.
3. Be willing to acknowledge the role or roles you are playing
Take responsibility for whatever part you are playing in the game. Accountability is power. You cannot change other people, only yourself. When you take responsibility for what you are doing you take back the choice and power to change it.
4. Be willing to look at the payoffs you get from playing those roles
Examine your own motives and rewards for participating in the drama or maintaining a certain role. What do you gain by being a Victim/Persecutor/Rescuer? What are the benefits of creating and participating in the drama rather than allowing everyone to be responsible for themselves? How much of your life is taken up with this drama? Take responsibility for and make yourself aware of the benefits you derive from playing a certain role or playing the game in general. Be aware that leaving the game may leave you with a life that is quite boring for awhile. This game is very dramatic, an emotional roller coaster. Walking away from it may leave an emotional void to be filled.
5. Disengage
Announce as honestly as you can to the other players what you think is happening and let them know of your intention to no longer “play”. Try to avoid blaming or attacking. Take responsibility for your part in the “game” and let them know as best you can what to expect from you in the future. “I’m no longer going to be responsible for making you feel good.” “I’m no longer going to engage in attacking or blaming you.” “I’m no longer going to look to you to take care of me.” Do not take responsibility for governing their behavior or trying to influence them to leave the triangle. Allow them to make their own decisions and be responsible for their own behavior. You are only talking about what you have chosen to do. Avoid lecturing them about what they should do. That is the Persecutor role.
6. Avoid being sucked into other people’s battles
Do not allow the other participants to suck you back into the interaction. If the Victim comes to you to tell you how badly the Persecutor is treating them, don’t engage. Redirect them to tell the Persecutor how they feel, not you. If the Persecutor comes to tell you how pathetic the Victim is, don’t engage. Redirect them to tell the Victim how they feel, not you. If the Rescuer comes to tell you how the Victim does not appreciate their efforts, don’t engage. Urge them to tell the Victim directly, not you. The goal is to avoid indirect communications of attacking, blaming or guilt. If you have a problem with someone, discuss it directly with them. Do not take it to a third party. Be responsible for expressing your own feelings and beliefs. Do not take on other people’s or pass yours to a third party.
7. Take responsibility for your behavior
Stop attacking and/or blaming. Persistently pursue truth telling and accountability and be aware of the effects they have. At this point it will be very easy to be cast in the Persecutor role. It will also be very easy to slip back into the Persecutor role. Be sure that your “truth telling” does not become blaming or attacking. Be sure that you only discuss your behavior, your decisions, your feelings. Do not take up responsibility for reporting, changing or carrying other people’s emotions, beliefs or behaviors. If the other members of the triangle refuse to disengage from the game you may have to limit contact with them in order not to be villainized, guilted, blamed or sucked back in. It is almost impossible to maintain honest, open, direct communications about what is happening with two other people who are heavily invested in denying it.
8. Breathe
It may be necessary to step back and catch a breath. Especially if this is a family of origin dynamic. Family dynamics are very, very powerful and we can find ourselves tap dancing like mad before we even realize the music has been turned on! Sometimes it may be helpful to separate from the other players, get quiet, recenter and refocus on what your goals are and what you responsible for. Remember – truth and accountability are the goals. Remember – these are your goals. They may not be other people’s. Remember – truth and accountability are what you are choosing to practice for yourself. Not what you are choosing to apply to others’ behavior. Attacking, blaming and guilt are to be avoided. Try to surround yourself with other people who do not play this game so you can learn new ways of interacting with people.
Walking away from a game such as this can be challenging. But it is worth the effort. You will slip when you first try to walk away and find that you have gotten sucked back in – again. Be gentle and forgiving with yourself. Remind yourself of your goals. Reestablish your boundaries. And try, try again. You will eventually get the hang of it.