Louboutins are the Best Shoes We Have, Expert Says
The New York Times's long-standing love affair with idealized therapy succeeds at selling me a subscription and fails at advocating for kids.
I’ve got to give it to the New York Times: they know their audience. It is full of highly educated1 lefty2 white3 people with more than average income4 who like to protest things5 that they have strong opinions about. We also have a pathological need to be able to answer the question: “Did you read that thing in the Times?”
So, I have a confession. I’m Owen Scott Muir, Medical Doctor. I’m the target audience. There is no way I am not going to read “that thing in the Times”. So, dutifully, I read their recent article from the Inner Pandemic series about how we have an amazing therapy for suicidal kids but few can access it. And I subscribed because I wanted to make sure I could get through a conversation this week without being an utter pariah amongst my mental health colleagues.
One of the strong opinions, as highlighted this week in this as well as another very misleading piece about polypharmacy by the same author, is a deep suspicion of mental health care that doesn’t fit our preconceived ideas of the Park Avenue Shrink: endlessly bespoke multi-hour evaluations, highly structured therapy, or better yet, Woody Allen-esque psychoanalysis. And as predicted by their excellent understanding of market demographics—here is my predictable dissent!
They have a track record of 💩posting psychiatry and psychiatric medications— and, at the same time, seem to enjoy a fascination with psychotherapy as the province of compelling eccentrics. Lest we forget the fabulous series of photographs of weird therapists chairs in their weird New York offices?
The Times loves to get a lot of mileage out of its particular erudite brand of 💩 posting, and they’re at it again in typically subtle form with their most recent piece about psychotherapy as a treatment for suicidal youth. Matt Richtel is the author of the piece, entitled:
‘The Best Tool We Have’ for Self-Harming and Suicidal Teens
Studies indicate that dialectical behavior therapy offers greater benefits than more generalized therapy. But treatment is intensive, and expensive.
The subtitle is, strictly speaking, accurate. The title itself is misleading. That misleading title- that’s a real problem. One of the difficulties in getting help to kids who want to die is that distorted ideas about what should be done are a barrier to what could be done. But it sells papers to a very specific audience.6
As a kindness to the rare reader who might not want to join this author in relentlessly socially enforced subscription to the New York Times, I will summarize:
The piece is about a type of psychotherapy called Dialectical Behavioral Therapy (DBT). The adaptation of that therapy, originally developed by Marsha Linehan7, for treatment of adolescents is outlined in a manual written8 by my colleagues Alec Miller and Jill Rathus. They are both psychologists9. I think the world of Alec and Jill, and when we first met, I will note with only a mild to moderate sense of irony, it was at a training for the other therapy modality with evidence for suicidal youth that was left out of the piece.10 This therapy- Mentalization Based Treatment (MBT)- is another very conspicuously overlooked answer to the question of what should we do for suicidal youth. For the past decade in the United States, however, DBT gets held up as the gold-standard in the popular press and in many training programs.
Nonetheless, if you check out the first page of Google if you ask it “What therapy works for suicidal adolescents?”research on the evidence base for MBT will show up.
Looks promising?! What does it find?:
Dialectical behavioral therapies were associated with reductions in self-harm (OR, 0.28; 95% CI, 0.12-0.64) and suicidal ideation (Cohen d SMD, −0.71; 95% CI, −1.19 to −0.23) at the end of treatment, while mentalization-based therapies were associated with decreases in self-harm (OR, 0.38; 95% CI, 0.15-0.97) and suicidal ideation (Cohen d SMD, −1.22; 95% CI, −2.18 to −0.26) at the end of follow-up.11
There are only two treatments that I am aware of that have shown positive results in randomized controlled trials for suicidal youth. One of them is featured in the article by the New York Times alongside a series of other essentially unrelated treatments. MBT- the one other therapy —with randomized controlled trial evidence in adults and adolescents for that matter— is completely omitted. This may sound like inside baseball and just a bunch of acronyms but for those of us who do this work day in and day out with families in crisis who feel like they are out of options, the details matter.
Here is an example of, off the top of my head, another plausible headline I could write, if I were an editor @ New York Times and wanted to report on something provocative and similarly biased:
‘Louboutins are the best shoes that we have, Experts Say’
Studies indicate Louboutins are able to make women taller, and nine out of 10 women prefer them. But the can leave blisters, and are so expensive they’re out of reach for most women.
Here is where the definition of words matter a lot, and the framing of a question becomes tremendously important, as is one’s understanding of science, of people, of how science is understood by people, and of how biased science can be when conducted by people.
The word best is not disambiguated in the title. I am similarly the World’s Best Dad. I have a mug that asserts this title belongs to me. And among the sample of individuals for whom that mug is a definitive statement, 100% of them will agree, I am, without a doubt, the World’s Best Dad.
Readers of this column, I imagine, might already expect a biased sample may have something to do with that skewed outcome. The mug was given to me by my adorable children – thanks Trent and Quinn! In any sample of my adorable children, I am the World’s Best Dad for 100% of them. And that’s the problem with research. The sample from which you draw your study participants also becomes the sample to which the conclusions are applicable. A broader sampling of children might reveal otherwise. The term for this is a problem with Generalizability of a research finding.
The NYT is fixated on a definition of the word best: This therapy wins!— in the particular research study the journalist happened to skim. I don’t think this definition captures all of the qualities that would make a treatment the wisest possible tool we could advocate for.
Let’s look at research about DBT in adolescence compared to treatment as usual. In this case, treatment as usual might also be referred to as general treatment. In randomized controlled trials of psychotherapy, where you’re trying to compare a new therapy to existing therapy, general therapy a.k.a. treatment as usual —it is used as the control group. It’s the sugar pill.
Problems With Biomedical Research: Episode 3982720287
To start, if suicidal youth are enrolled in a research study, they met the strict inclusion and exclusion criteria for that research. This very fact leads to a limited and biased sample. Inclusion criteria usually means they have not only the disorder that you’re looking to study, in the case of DBT it’s usually borderline personality disorder (not mentioned in the Times’s piece, but that is the diagnosis that DBT was developed for and studied in). Keep in mind that not every suicidal person has borderline personality disorder, not by a long shot.
To be enrolled in the study, you also need to not meet any of the exclusion criteria, which often include common complicating factors like having any other problems which exist in the life of many troubled adolescents. These include: drug problems, significant medical problems and many other psychiatric disorders. These exclusions are the confounds that actual child and adolescent psychiatrists are faced with every single day.12 A recent study on DBT in queer youth included the following in its methods section:
To ensure efficacy and promote commitment to the treatment, participants were required to not miss more than four groups or individual sessions.
Pop “fundamentals of research” quiz: does anyone think that teenagers who miss sessions and teenagers who won’t miss sessions might be different kinds of kids? Kids who don’t qualify for these studies don’t typically get much of a choice as to what treatment modality their family is going to be able to afford and access in their area.
For specialized mental health treatments like these, unfortunately insurance companies reimburse so little that the few clinicians trained in them are often out-of-network. Mental health parity violations strike again! For individuals suffering with autoimmune disorders, their treatment routinely runs between $80,000 and $250,000 a year for just one medicine like Humira or Cocentyx. Insurance pays for those and no one is writing thinly veiled anti-rheumatology articles in the Times. Meanwhile therapists face public criticism and pressure to accept insultingly low insurance rates for their expertise.
There are a lot of choices you don’t get. You don’t get to choose which illness will befall you. You really don’t get to choose if your illness will be a research or commercial priority. Kids and families who are desperately struggling to find help for their suicidal despair don’t get to choose from every available option. They only get to choose from what’s available to them—and pray it’s among those (prior) authorized sources of succor insurance deigns to reimburse, “whatever the cost!”
How Much is It?
Like many fancy academic medical institutions, Columbia has a DBT program—what does it cost?:
$300 daily for the program (does not include cost of individual therapy and psychiatry visits)
What’s Happening in this Treatment Anyway?
The context in which DBT is so much superior however needs to be noted. DBT is a superior treatment in the time course of a DBT study for kids and families who meet the criteria for the study. It may be an excellent treatment for others. But given current payment models, it’s really unlikely that we’re gonna find out anytime soon. Because people are having this held up as the best hope. Then, predictably, they will be demoralized when they can’t get their insurance to pay for it. Which I’m here to promise you, it won’t. Not without a fight. There may even been a footnote (or many) devoted to this by the end. That is called foreshadowing.
This is an intensive treatment. What that means is there is weekly (or daily in Columbia’s program!) individual therapy, weekly multi-family groups, where your whole family and other families all have to get together at an inevitably inconvenient time for working families. Furthermore, there is homework, and the kids in the studies and their parents have to agree to do that homework16. Moreover, there is the availability of coaching calls in the context of possible self injury, which requires therapist who are interested in taking those coaching calls pretty much at any hour of the day or night17. All of which is to say, this is a whole to-do of a treatment. No wonder it’s so freaking expensive. It requires a large team. I am bullish on teams in healthcare. But the problem with large teams in healthcare is that they are as expensive as you think they are, particularly when they require brand-name extensive and costly training by an organization. In this case Behavioral Tech dominates the market for brand name DBT therapy training. This is a product. With a capital P.
Does highly structured brand-name therapy outperform generic therapy in people for whom brand-name therapy is a reason they might want to enroll in a study? That is the question that is answered.18
The problem with both this reporting and dialectical behavioral therapy for adolescents itself is that it’s applicability is restricted to a very specific audience.19
Say it with me, and say it loud, if a treatment is not accessible, if it’s not able to be made accessible, it doesn’t freakin' matter20 if it works for a few people. Particularly not if those people exclude the most vulnerable and children of color. Cause that—I think there is a word?—oh, structural racism.
Perfectus Delenda Est
Cato the Censor might well have ended all speeches with the above (roughly translated, “perfectionism must be destroyed”) instead of his catch phrase if he was a senator now21. We need answers that work reliably, and that are scalable. Scalability is my criteria not just because it makes venture capitalists happy. It’s a criteria because the problem is at a massive scale and it is an abdication of our moral responsibility to relieve the suffering of children and families who want to kill themselves if what we’re doing is restricted to reporting on bespoke treatments accessible only to wealthy white people in the high cost of living cities where therapists tend to gravitate towards and therefore are not able to take insurance and pay their rent.
It’s worth noting that there is also a limit on who most therapists will see in their fancy private practices: children who have problems that are bad, but not so bad that they scare off the DBT therapists. And believe me, those patients exist. To quote one such individual, “Margaret”, from the Atlantic Monthly:
“Because I take up so many more resources than other patients,” she says. “When you call your therapist because your boyfriend left you and you’re sad about it, they can wait a few hours before calling you back. When you’re going to kill yourself, they have to immediately drop what they’re doing. I tried calling people from Psychology Today—you know how they have those listings? They’re nice at first, but when I tell them how suicidal I’ve been, all of a sudden, they don’t really have time, and they don’t know anybody they can refer you to ... nobody wants to work with someone like me. It’s a risk, because if we do kill ourselves, it’s traumatizing and messes them up. And also, they can get sued.”
I have to give “Margaret” credit. She wasn’t wrong. After the discharge from the hospital that she was languishing in during the time she provided that interview, she finally found a team willing to work with her. And that team helped her return to school, to form new peer relationships, to travel and to feel like more than a “difficult patient” who is beyond help. But she didn’t underestimate the risks of her lifelong severe psychiatric illness. She eventually died by suicide. Her mother sued the psychiatrist(s) and hospital involved at the time of her death. I know, because one of those psychiatrists is your author. The lawsuit was dismissed—with prejudice— within a few months. My life’s work has been dedicated to helping those similarly suffering. It didn’t end with that dismissal and we as a field cannot simply dismiss taking care of patients like “Margaret” because of medicolegal fears.
This “Suicidal Crisis” the Times Spotlights has Been My Calling
"Margaret’s" death by suicide was prior to the evidence my co-authors, colleagues and I later worked so hard to gather. It is evidence on newer treatments that were considered experimental and unproven when “Margaret” was in my care.22 The memory of her struggle did more to change the course of our research than than she could have imagined. The FDA approval of the treatment that could have saved her life (had it been more accessible a second time for her) was just granted, this week. Make no mistake about it, what we gather evidence on is biasing. It’s as much as the bias, as belabored above, on what the evidence gathered ends up demonstrating. And it’s a life or death issue.
Medications get studied. Devices get studied. But promising therapy research on suicide and BPD languishes for lack of research dollars. The evidence doesn’t exist for the most suicidal patients who stand to benefit the most from effective psychotherapy. Some common conditions, like Narcissistic Personality Disorder, have only the most basic questions asked thus far. There is hope! Just because the research hasn’t been done—yet— doesn’t prove “nothing works.”
Practically, my above argument, ardent though it may be, is, in a way, beside the underlying point: we are unwilling to invest in answers for those suffering from suicidal despair. This is markedly and catastrophically worse than for other health conditions:
Up to 5.9% of the population suffers from BPD — more than twice that of schizophrenia and bipolar disorder combined. "Borderline Personality Disorder" is the most viewed term on NIMH’s website and yet it receives less government funding than any other mental illness.
The advocates for DBT have done a fabulous job of getting it studied in adults and even in kids. The same cannot be said for other plausibly scalable solutions, for example mentalization-based treatment23 (MBT24) or another promising treatment called General Psychiatric Management for BPD25 (GPM).26
Ironically, that GPM approach is designed to be inexpensive and highly scaleable so that all mental health professionals could become proficient in working with this population—and thus who is going to make enough money off it to make it worth their while? A healthcare system that can only profit off of the expensive is the one that will feature endless expense. And it does, profitably:
This dynamic deprives patients of investment into research on help that might be effective AND accessible because it doesn’t align with the sadistically misaligned incentives that we accept as readily as Thomas Anderson once accepted the Matrix.
There Is No Spoon
Where is our Neo? Where is the reporting and investment in treatments that work in ways that are most scalable and that could help many more kids27?
We spend $4.6 trillion a year, and more every year, on healthcare in the US. If we can’t find a few billion dollars28 to pay for the most effective treatment for suicidal kids, no matter how complicated it is, maybe the Times is reporting on the wrong story in the first place.
In related news, 7 carat diamonds are the best wedding ring we’ve got.29
—O. Scott Muir, M.D.
The Frontier Psychiatrists has possibly saved you whatever it would’ve cost to subscribe to The NY Times. Now you can subscribe to The Frontier Psychiatrists. It’s about aligning incentives!
Post-Script Addressing Ethics and Intentions: None of the above is intended to undercut the unbelievable power of Dialectical Behavioral Therapy to save the lives of people who desperately need it. In any just world, great psychotherapy that worked really well for people who are suffering would be a first line interventional care. And it would be paid for thusly. This is not the world that we live in right now. That’s the story. The Times seems intent on alarmism over someone’s blood pressure medication choices when they’ve come in with a bullet wound.
17. 72% of the paper’s readers have at least a university degree.
(Pew Research Center)
Compared to other popular left-leaning outlets, The New York Times has the most educated readership. While 72% of the readers have at least a university degree, another 21% say they’ve finished college. Only 7% of the readership doesn’t have a higher education degree.
91% of The New York Times readers identify as Democrats.
(Pew Research Center)
As for political affiliation, more than 9 in 10 people who cite The New York Times as their go-to news source identify as Democrats. For comparison, only 7% say they are Republicans, while the rest either identify as Independents or don’t have any political leanings.
More than two-thirds of The Times’ readers are white.
(Pew Research Center)
The New York Times audience demographics also reveal a significant discrepancy in its racial and ethnic makeup. According to research, 71% of the paper’s readers are white, 10% are Latino, 4% are Black, and the remaining 15% belong to other groups.
38% of The New York Times’ readers earn more than $75,000 a year.
(Pew Research Center)
Not everyone who reads The New York Times comes from an affluent household. According to the most recent survey, 25% of the paper’s readers earn between $30,000 and $74,999 per year, and 26% have an annual household income under $30,000.
The average Times reader is well-informed and politically opinionated.
Research shows that 40% of the readers care about overseas events, and 24% are also eager to learn about other cultures and lifestyles. Additionally, more than 33% of the paper’s readers say they would participate in civil protests regarding the issues they care about.
The Times, lest we forget, is selling digital subscriptions to newspapers. Monetize the rage of well educated health professionals: a business plan.
Who is, not for nothing, the subject of a glowing times biopic a few years back, and that’s What I consider a recurring character in the New York Times storyline about psychotherapy!
And a somewhat remarkable review by Rebecca Emma Kaplan, LMSW as published in JAACAP is cited above…it’s a remarkable manual. It can be a lifesaving treatment. Her take is invaluable, and emphasizes the structural and inequities in it elegantly, as both a social worker and someone who has personally benefited from the treatment for her own struggles with suicidal ideation and self-harm.
Although it might not be clear to reporters of the Anti-Psychiatry Beat, psychology is a different discipline than psychiatry. Psychologists get a graduate degree at a doctoral level, and never go to medical school. Medical doctors, who go to medical school, and eventually sub-specialize in psychiatry do a different job. Often times, the New York Times seems to call on Psychologists to comment on medication, which is a little bit like asking a doctor of physical therapy to offer definitive comment on which scalpel to use in hip replacements, writ large. Same organ system, different discipline. Both have important roles to play and lanes to swim in.
Why yes, I am a co-author on that book about that other therapy if you happen to click through! There are no royalties to disclose, sadly.
“Follow up” is a time point later than “the end of treatment,” FYI.
We don’t get to exclude those patients neatly from our clinical work. Or at least, we should not.
Which can range between 200 and $1000 an hour in my city, and in some cases more.
Initial evaluations for kids at a place like the NYU Child Study Center were $2100-$2300 when I was in training there, and that was years ago.
This was not cherry picking. It’s literally the first thing I looked up and could see a price for.
So, again, thinking of selection bias, if you can imagine a cohort of young people so distressed they want to kill themselves, but so willing to work on it both they and their families are willing to agree to therapy in advance that requires additional homework, you can get a sense of what a strange sample these research participants might be compared to most distressed teenagers, who have an ambivalence towards things like extra homework and treatment in general.
To be clear, I take a lot of calls from suicidal patients, and will take many more I’m sure in the course of my life. I’m not dunking on dedicated therapists. I’m just saying I don’t generally get paid for it, and they don’t get paid enough for it.
Similarly, 100% of individuals shopping at Bergdorf Goodman such as my wife, when asked if they prefer a cheap knock off, indicated a preference for Louboutin and Chanel.
There is significant research going on right now by many researchers across the world attempting to figure out which parts of DBT matter the most, which parts are scalable, how they can apply to different cultures, and I applaud these efforts. None of these, it’s worth noting, are reported by the Times either.
as a matter of public health importance.
And I’m an official trainer in the GPM technique and proposed it’s adaptation for use in adolescents way back in 2017.
Which has non-inferiority trials compared to dialectical behavioral therapy in adults but not in children, as of yet.
And, of course, ignore how much they’re willing to pay for injectable biologics, brain scans, surgical implants, hospital rooms, and insurance premiums?
Yes, billion, I used that unit of measure because UnitedHealthcare, for example, makes $2 billion in profits every single month. So don’t tell me that DBT is too expensive. Don’t tell me that anything is too expensive. If we’re not talking about stealth bombers, we’re not talking about expensive when it comes to healthcare. There are 50,000 train DBT therapists and with the profits UnitedHealthcare is making they could pay each of them $480,000 a year. Thus concludes this footnote which I will refer to as the DBT Therapist Employment Act of 2022.
It does not follow that they are the only ring one should consider a for a proposal. I myself went with a beautiful and modestly priced black diamond for my slightly edgy/hip yet still classy wife because, like mental health treatments, it really depends on the needs and preferences of the recipient.