When a mental health clinic, online referral service, or private practice offers “evidence-based” psychotherapy, that certainly sounds like a selling point.  It suggests solid science supports the therapy offered — and that competing services lack this support.  But what does this phrase really mean?

“Evidence-based medicine” first appeared in the medical literature in 1991.  It cast doubt on physicians’ clinical intuition and anecdotal experience, reminding them that science should guide medical …

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Two cars arrive at a stop sign at the same time.  Both start into the intersection.  One driver speeds through, while the other jams on the brakes, avoiding a collision.  This driver feels insulted, offended, diminished.  Who the hell does that other driver think he is?  He nearly killed me!

This scenario, and countless others involving merge lanes, contested parking spaces, and aggressive rush hour traffic, are set-ups for road rage. …

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It has become a sign of legitimacy to call a personal problem “medical.”  This aims to distinguish the problem from those of morality or character.  It implies both that the problem is serious, and that it is unbidden and largely out of the sufferer’s control.  Unfortunately, it isn’t clear what exactly qualifies as “medical,” so this label serves more as a rhetorical device than a scientific finding.

Alcoholism is …

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In Toronto on April 23, 2018, Alek Minassian intentionally drove a rented van into pedestrians, killing ten and injuring at least 15. Later the same day, Constable Ken Lam of the Toronto Police Service arrested Minassian after a brief, tense standoff. As seen in a widely circulated video, Minassian dared the officer to shoot, and feigned drawing a gun, most likely to commit “suicide by cop.”

Constable Lam, however, …

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In her recent New Yorker article, “The Sorrow and the Shame of the Accidental Killer,” author Alice Gregory claims there are no self-help books for anyone who has accidentally killed another person.  Nor published research, therapeutic protocols, publicly listed support groups, nor therapists who specialize in their treatment.  She profiles several such tormented souls who bear their burdens largely alone.

Yet dealing with guilt, shame, and regret is a mainstay of …

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A woman recently requested a medication evaluation at the suggestion of her psychotherapist.  The caller told me her diagnosis was borderline personality disorder. She hoped medication might ease her anxiety.  She also admitted that two other psychiatrists refused to see her because she was too “high risk.”  I asked if she was suicidal.  Yes, thoughts crossed her mind. However, she never acted on them, and was not suicidal currently.  I …

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In a world of diverse mental health treatments and treatment settings, psychoanalysis and psychodynamic psychotherapy have lost their former prominence.  Only a small fraction of patients have the time, money, and interest to engage in long-term, open-ended mental exploration — even if doing so would get to the root of their problems and lead to lasting improvement.

More commonly, emotional distress is dealt with in emergency departments, in crisis clinics, on the medical and surgical floors of hospitals, in …

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Prior to the release of DSM-5 in 2013, I referred at times to the pocket copy of DSM-IV parked in my office bookcase.  The main reason was to enter the right diagnostic codes on insurance forms.  I also sometimes quoted DSM criteria to show a patient that ADHD can’t arise in adulthood, that daily mood swings are not characteristic of bipolar disorder, or that six months of sobriety is still “Read more…

Again and again in therapy I find myself emphasizing the distinction between feeling an emotion and acting on it. Many patients, and non-patients too, take undue responsibility for their emotions, as though feelings were volitional behaviors, the result of a choice.  Often there is a stated or implied should: “I should feel this, not that.”  Note how commonly people blame themselves for feeling, or not feeling, a certain emotion:

“I should be more grateful after all she’s done for me.”

“It’s wrong of …

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Some maladies that attract psychiatric attention are unequivocally brain diseases.  Huntington’s disease.  Brain tumors.  Lead poisoning.  However, these are not psychiatric diseases.  Huntington’s is a genetic abnormality diagnosed and treated by neurologists.  Brain tumors are managed by neurosurgeons and oncologists.  Lead toxicity is treated by internal medicine.  Indeed, a long list of medical and surgical diseases include psychiatric features: stroke, anoxic brain injury, meningitis, lupus, diabetic ketoacidosis, and febrile delirium to name a few.  One important …

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