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Clinician's Digest - Page 2

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Despite his repeated condemnation of groups misusing the paper for discrimination or opposition to equal rights, until recently Spitzer maintained his position that sexual-orientation change was possible for a very rare set of "highly motivated" individuals. This changed when journalist Gabriel Arana chronicled his experiences with conversion therapy in an article titled "My So-Called Ex-Gay Life," which appeared in the April 2012 issue of The American Prospect. During an interview for that article, Spitzer asked a surprised Arana to print a retraction of his controversial study. "In retrospect," Spitzer told Arana, "I have to admit I think the critiques are largely correct."

Spitzer's retraction made national headlines, including a front-page profile in The New York Times. While some believe the retraction will severely undermine the efforts of "ex-gay" proponents-Wayne Besen of Truth Wins Out wrote a statement saying the retraction "kicked out the final leg from the stool on which the proponents of 'ex-gay' therapy based their already shaky claims of success"-others suspect that these groups will use alternative sources to justify their efforts. For example, days after Arana's article appeared, NARTH posted on its website an interview with Nicholas Cummings, a former president of the American Psychological Association, who said he currently sees "a need to form an organization that would recruit straight white males, which are underrepresented today in the APA," and that he has personally experienced "success" treating individuals who wanted to change their sexual orientation.

The American Psychological Association has maintained a clear stance on sexual orientation conversion therapies, stating in their 2012 Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients that "same-sex attractions, feelings, and behavior are normal variants of human sexuality and that efforts to change sexual orientation have not been shown to be effective or safe." Similarly, the American Psychoanalytic Association has stated that "the goal of analysis with homosexual patients is understanding," and that "psychoanalytic technique does not encompass purposeful efforts to 'convert' or 'repair' an individual's sexual orientation."

Gary Diamond, an associate professor of clinical psychology at Ben-Gurion University, says that Arana's experiences with conversion therapy are consistent with the kind of "horrible experiences of feeling guilty and shamed" expressed by many others who have undergone or been coerced into such treatments. Instead of focusing on changing sexual orientation, most mental health professionals advocate an approach with lesbian, gay, and bisexual clients that supports coping with the effects of stigma and discrimination from parents, peers, and society at large. "Ultimately," Diamond says, "what people want is acceptance."

Endless Therapy? Stop it!

This spring, professional counselor Jonathan Alpert rankled many in the mental health community with his provocative New York Times article titled "In Therapy Forever? Enough Already." In it, Alpert suggests that ineffective therapy is "disturbingly common," and that most people are simply in treatment too long, happy to empty out their checkbooks in exchange for time spent basking in their therapists' warm platitudes of acceptance.

"There's a difference between feeling good and changing your life," Alpert writes. "Feeling accepted and validated by your therapist doesn't push you to reach your goals. . . . It might even encourage you to stay mired in dysfunction." Alpert endorses an aggressive therapeutic approach focusing on the active provision of opinions, advice, and structured action plans. He says most people seek therapy not for complex mental disorders, but for "discrete, treatable issues," which can sometimes be managed in less than an entire session.

Critics quickly responded. At Forbes.com, Todd Essig, a training and supervising psychoanalyst at the William Alanson White Institute, wrote that "the article is dangerous. It perpetuates the myth that psychotherapy is inefficient, ineffective snake oil, relaxing to be sure, but snake oil nonetheless." Essig accuses Alpert of "cherry-picking" research findings in service of media self-promotion and marketing for his new quick-fix self-help book, Be Fearless: Change Your Life in 28 Days. Indeed, Alpert does seem to misrepresent the findings of at least one study in his article, when he says that a recent Journal of Affective Disorders supports the therapeutic efficacy of "active, engaging, and extroverted therapists." What he fails to mention is that less intense and task-oriented therapists in long-term therapy actually produced the best outcomes with a three year follow-up.

The endless debate over how long is too long for psychotherapy is the ultimate case of analysis interminable. The practice of psychotherapy exists at the crossroads of medical and wellness approaches to health: a medical model works on discrete disease entities with targeted solutions and outcomes; a wellness approach focuses on lifestyle changes and works toward cultivating meaning and well-being. Sometimes the road to health is short, but sometimes it's long. One thing is for sure, however: when you're stuck in a dreadfully stagnant and unproductive treatment, just stop it!

Head Injuries and Depression

A spate of recent suicides among former NFL football players has again shone a spotlight on the debate over the lasting effects of repetitive head injuries and multiple concussions. Former San Diego Charger Junior Seau's death follows, and shares similar circumstances with, the suicides of Chicago Bears safety Dave Duerson in 2011 and the Atlanta Falcons' Ray Easterling earlier this year. Both Duerson and Easterling were believed to have suffered from chronic traumatic encephalopathy, a neurodegenerative brain disease, which can be diagnosed definitively only after death. The disease, thought to be caused by recurrent head trauma, manifests in early cognitive deficits and emotional problems, such as intense anger and depression. Shortly after Seau's death, his family was left to decide whether they should donate his brain to the Boston University Center for the Study of Traumatic Encephalopathy, a group that studies the disease posthumously in deceased former football players.

While the problem was previously believed to be a rare phenomenon following a lifetime of big-league hits, accumulating evidence suggests that traumatic brain injuries (TBIs) and their consequences are a serious and widespread public health problem. According to the Centers for Disease Control, an estimated 1.7 million people sustain a TBI each year in the United States. While some incidents are serious and even fatal, the injuries are most frequently classified as "mild" and are sustained during falls, bike crashes, and motor-vehicle accidents. What's more significant is the likely large but unknown number of head-trauma incidents that go unreported and untreated.

Even mild TBIs can have serious consequences. Major depressive disorder (MDD) is at least three times as likely to be present in those with a TBI, and the risk increases with severity of the head trauma. MDD and similar mental health illnesses cause more lasting disability and risk (including a higher rate of suicide) than the traditional cognitive and physical impairments associated with the actual head injury. Unfortunately, MDD and anxiety disorder diagnoses are frequently overlooked in patients with TBIs, given their overlapping symptoms with postconcussion syndrome, which includes fatigue, sleep disturbance, and poor concentration. This diagnostic conundrum is further complicated with forensic issues, such as malingering and symptom exaggeration, given the increased number of TBI patients involved in civil litigation related to their injuries.

Despite evidence supporting the effectiveness of mental health interventions, including antidepressants, psychotherapy, and counseling after TBIs, a recent large-scale longitudinal study by researchers at Harborview Medical Center in Seattle found that among those meeting criteria for MDD in the first year following hospitalization for mild to severe head injury, less than 50 percent were ever treated for depression. While high-profile cases like Seau's bring attention to safety issues in athletics, you don't have to be a big-league sports star to experience the physical and emotional consequences of a head injury. Whether suffered under the Friday-night lights or from a tumble on a bike, we too easily overlook that even minor hits can have lasting impacts.

Resources

Partisan Personality:

American Psychologist, 61, no. 7: 651-70; Current Biology, 21, no. 8: 677-80; Psychotherapy, 39, no. 3: 245-60.

"Ex-Gay":

http://prospect.org/article/my-so-called-ex-gay-life; American Psychologist, 67, no. 1: 10-42.

Endless Therapy:

http://www.nytimes.com/2012/04/22/opinion/sunday/in-therapy-forever-enough-already.html; http://www.forbes.com/sites/toddessig/2012/04/23/jonathan-alperts-mis-statements-and-possible-misconduct/

Head Injuries:

Journal of the American Medical Association, 303, no.#19: 1938-45; http://www.mentalhealth.va.gov/docs/TBI-Depression_ConsumerGuide_04-13- 2011.pdf

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