Tuesday, January 27, 2015

If All the Docs are Doing it, is it not Malpractice?

Part of the legal definition of malpractice includes the idea that the treatment provided falls below the accepted standard of practice in the medical community.  In other words, it must be shown that the practitioner was acting in a manner which was contrary to the generally accepted standard operating procedures that are currently being widely used by other physicians in the city in which the doctor practices.

For a malpractice case to be successfully pursued in court, the treatment must also be shown to be negligent and of course result in some quantifiable harm to the patient. But what happens if certain harmful procedures were being widely performed by almost all of the other doctors in the community? Even if the harms are predictable and significant, is a doctor protected from liability just because "everybody's doing it?"

Many mothers back in my day used to answer their kids' protestations that "other kids get to do it!" with, "If everyone jumped off a bridge, would you do it too?" I can't speak for others, but mindlessly following the herd was not something that was encouraged in my family system.

I do not know off hand what the answer is to the question above. Perhaps some malpractice attorney who happens to read this might write in with the answer. The reason I thought of this question was something I recently read in the psychopharmacology (psych drug) newsletter Biological Therapies in Psychiatry (July 2014) about how often kids are monitored for side effects when they are prescribed psychiatric medications.

Regular readers of this blog know that I think that the diagnosis of pediatric bipolar disorder is in the vast majority of cases a scam, and that prescribing antipsychotic drugs to children to control their behavior is a reprehensible activity. Kids should not be sedated into being less affected by family dysfunction.   

That would be bad enough, but what is worse is that antipsychotic drugs have potentially dangerous side effects. Particularly with the newer, "atypical" antipsychotics, there is a significant risk of causing weight gain, type II diabetes, and high cholesterol. These risks may be higher in children and adolescents than they are in adults.

If a patient is psychotic, the benefits of these medications generally outweigh the risks, especially if the patient is monitored for the emergence of these side effects. And there are few other options. (Sometimes one drug in a class will do it in a given patient, but not another drug in the same class). If patients are not psychotic, and very few kids are, the benefits decidedly do not outweigh the risks.

At the very least, the doctor should take blood tests periodically to see if these side effects are developing. You would think that doing that would be the standard community practice.

Well, if you thought that you would be wrong. 

In a retrospective study by Delate and others (JAMA Pediatrics, 2014 May 5) of pediatric patients started on an atypical antipsychotic within the Kaiser Permanente system HMO in Colorado, the authors found that only 1 patient out of 1023 received the full recommended panel of baseline and follow-up blood monitoring!

That's right; you read correctly. 1 out of over 1000, or one tenth of one percent. Of course we don't know if kids in other health plans are being treated this negligently, but I would not be surprised.

So if almost all of the doctors in a community are making little kids jump off bridges, does this mean that they are not going to be held liable if they are sued for malpractice?

Tuesday, January 20, 2015

Family Communication: Countering Relatives Who Go Off on Tangents

In my blogposts about family metacommunication, one issue I discussed is the tendency of people to change the subject when discussing anything touchy. When a person is afraid to or does not want to go into depth in discussing a particular repetitive interactional pattern with a family member, for whatever reason, a subtle switch from the issue under discussion to some other matter is often a successful strategy for avoiding further dialogue about it.

This is particularly easy to do if there are a whole bunch of similar issues that are all inter-related and intertwined with one another. As I wrote in the previous post: 

Another related misdirection strategy is to mix several separate but highly interconnected issues so that none of them is ever completely discussed. For example, one woman was in a complex family system in which her husband would find ways to distract her from her anger at her parents and vice versa. Whenever she expressed anger at one of her parents, the husband would do annoying things to draw away her anger from her parents towards him Similarly, when she was ready for war with hubby, one of her parents would act out and draw her wrath towards them.

The woman's genogram revealed that the problems in this system were related to gender issues (whether men should take care of women or women should pursue independence), concerns regarding the adequacy of males in the family to take care of their women (her husband felt that he was supposed to protect his wife but felt inadequate to do so and angry about "having" to shoulder the responsibility) and even class (how much money was being brought in).

The discussion would change from one of these aspects of the problem to another at the drop of a hat. Because the aspects were all so interconnected it was indeed difficult to talk about any one of them without talking about the others. For example, when the issue of the husband's adequacy came up, the issue of why he was like that would also arise. Because the subject of any conversation jumped around, however, any conversations about the issue would end up going in circles with nothing being resolved.

In this post, I want to discuss another useful strategy under these circumstances for keeping family metacommunication on track in order to get to the bottom of a single issue. Another way to look at the problem of subject changes is that the mix-up of issues allows people to go off on a tangent that is related to - yet different from - the main theme the metacommunicator is trying to clarify.

The trick here is to remember the definition of a tangent from your old geometry class in high school. Tangents are related to circles, and look like this:

If you go to the tangent line and trace it backwards, it always goes right back to the circle. Analogously in metacommunication, the "circle" is the main theme that ties all the different tangents together.

Any tangent someone goes off on can be thought of as just another example of the main theme - the circle in the diagram.

As an example, let us take a hypothetical situation in which there is a highly conflicted relationship between a mother and a daughter who come from a typical highly dysfunctional family - one characterized by many examples of major gender issues common to many members: the females getting involved with men who are drunk, abusive, and/or cheating; whether or not they should leave relationships with such men; expressing anger at such men; mothers who do not protect their children from abusive men or from witnessing domestic violence; conflicts over being tied down by children leading to neglect and invalidation of them; enabling children who don't take care of themselves; depending financially on either unreliable men or good providers who mistreat women, and so on and so forth.

There are indeed families characterized by all of the above conflicts- over several generations. If there are several sisters, aunts, great aunts and female cousins acting out several of these themes, one can see how easy it would be to subtly avoid focusing in depth on any one theme, or for that matter, on any one relationship.

So what might tie all of these gender-related themes together as they play out in metacommunication about problematic behavior patterns between a mother and her adult daughter who has children of her own?

Here we can make use of the concept described in a previous post: intrapsychic conflict leading to ambivalence leading to mixed and/or contradictory messages. Anything the mother says to her daughter regarding any of the above behaviors can be translated into a message to the daughter to either "act (or relate to the issues) like me" or "do not act (or relate to the issues) like me." Usually both within the very same conversation!

In this case, a good strategy might be for the daughter to express confusion about what the mother is trying to tell her in terms of following or not following mom's example no matter which aspect of the gender dysfunction is brought up. She might say something like, "Gee Mom, sometimes it sounds like you are criticizing me for doing the same things you do, while at other times it sounds like you are criticizing me for not doing them. I'm confused about what you think is the right strategy when, for example, my ex-husband keeps calling me on the phone several times a day."

A typical dysfunctional conversation might go something like this:

Mother: "I told you to block his phone number and stop talking to him."

Daughter: "But you let Dad keep bugging you all the time."

Mom: "Well, I do that for your sake 'cause I know you still care a lot about him, so it's better if we are civil to each other."

Daughter: "But wouldn't that also apply to my sons from my ex?"

Mother: "Well you don't seem to want to be bothered with your kids' feelings half the time anyway."

In this example, the mother has subtly changed the subject from how to handle an ex-husband to the daughter's parenting practices. If the daughter were to engage the mother on that issue, the mother might then talk about how the daughter is still financially dependent on her ex and needs to support herself better so she can get rid of him. Nothing would ever be resolved.

The counter-strategy is to take each tangent the mother goes off on and reconnect it to the circle or main theme. Any criticism the mother makes of the daughter on any of these inter-related subjects can be used as yet another example of how the mothers statements confuse the daughter in regards to whether or not she should follow her mother's example.

If the daughter starts with the statement above describing her confusion about whether or not mother thinks the daughter should emulate her, and the issue of the stalking ex comes up, the daughter would not say, "But you let Dad keep bugging you all the time." She would instead say, "I'm confused when you say that, cause that sounds like you are saying I shouldn't let my ex keep bugging me like you put up with Dad."

If mother then brings up her having put up with Dad for the patient's sake, that of course contradicts mom's initial advise for the daughter to cut off her ex when there's a child involved there. The daughter might then bring up that seemingly contradictory advice as a way to get back to the circle once again. 

The daughter would be ill-advised to come right out and accuse her mother of being hypocritical, as that would usually lead to the mother becoming defensive. Instead, she could blame her own confusion about what the mother is trying to say:

"Well I'm again kinda confused now. Are you saying I should handle it like you did for the sake of my sons, or that I should do the opposite of what you did and cut off my ex?"

Of course, this strategy could have good results, but it could also backfire.

The mother might at that point be struck by how she is giving the daughter double messages, which might then allow her to take pause and start to discuss why she herself might be confused on these issues - a good result. On the other hand, the strategy might also make her feel guilty and want to change the subject yet again. 

Mom might try the strategy of saying that her situation with the daughter's father is somehow different than the daughter's situation with her ex. Naturally, in some ways every situation is somewhat different, but in doing this she would be ignoring all the ways in which their situations are similar.

Figuring out the next move on the daughter's part would probably require the services and advice of a knowledgeable therapist. A therapist can tailor a counter-move for the daughter, using his or her knowledge of several different things: 

Knowledge of the mother and daughter's prior interactions; the therapist's own experience successfully countering the daughter's having done the very same thing to the therapist as her mother does to her within the context of psychotherapy; and information from the genogram about the source of the mother's ambivalence that can be use to empathically advance their conversations toward problem resolution.

Tuesday, January 13, 2015

What Happens if Adults with Borderline Behavior Start to Act Better?

People who have dealt with those who have been diagnosed with borderline personality disorder (BPD) often wonder why those folks persist in their often infuriating as well as self-destructive behavior when it seems so obvious that they are making themselves as well as everyone who cares about them completely miserable. 

When I first started to treat them, I know I did. These patients were not psychotic, nor were they stupid, so why did they persist in dysfunctional behaviors in the face of overwhelming evidence of their consequences. So I started asking the magic, Adlerian question: What would happen if you got better and stayed better?

As I described in that previous post, patients would often answer with the non-answers, "I'd just find some other way to screw things up" or "I cannot even imagine what that would be like." I would not accept those "answers" and pressed on.

When the answers finally started to emerge, I was totally amazed. One thing that might happen was described in my very last post. If a patient with BPD got better, their families would run for the hills. Exile them. Shun them. Abandon them. Anyone wonder why those with BPD have "abandonment issues?" Wonder no more.

But abandonment was far from the worst or the most likely outcome when patients acted beter.

I found that something family therapy pioneer Murray Bowen described was quite real - only that it was the just the first thing that would begin to happen before things got far far worse.

I found that the power of family members to invalidate anything a therapist tries to teach a patient should not be underestimated. As first pointed out by Dr. Bowen, they will literally gang up on a patient with messages that scream, roughly translated, "You're wrong! Change back!"  Previously uninvolved family members may come out of the woodwork, and previously sympathetic family members may suddenly turn on the patient and scream things like, "HOW CAN YOU TREAT YOUR MOTHER LIKE THAT!?!" 

I dubbed this phenomenon "clustering." Try to imagine what it would be like if everyone you know and loved started to come after you like that. If you don't think you would wilt, you are kidding yourself. And that would be true even if you came from a family that was relatively functional to begin with. Imagine having been invalidated like that for your whole life.

As I said earlier, however, that would only be the first thing that would happen if someone with BPD started to act better. The next thing that happens is that the parents start to act out in alarming and frightening ways. I'm talking about things like parents making suicide threats or actual attempts, increasing drug or alcohol abuse to alarming levels, worsening domestic violence, family members getting thrown out on the streets penniless, or any children left in the home starting to be abused, neglected or molested. You know, minor, inconsequential stuff.

Furthermore, as first pointed out by Lorna Smith Benjamin, in "borderline families" all these problems would be blamed on the patient, who would be subtly expected to somehow exert control over them.

Think you'd be able to turn your back on your family if all this happened to you? Very few can. Even if you could, it would only be because your family would, through their own behavior, engineer your dismissive attitude - so that you would continue to not only be their scapegoat, but so they could also label you as an uncaring son of a bitch as well. 

Americans like to think that they don't care what their families think of them. Horse manure!

In response to all of this, individuals with BPD usually start to actively undermine ("spoil") any efforts anyone might make to encourage them to continue with their "good" behavior - without telling anyone (including a therapist if they have one) about any of their family's behavior - and revert right back to the way they had always been. 

Sunday, January 4, 2015

Addict Cleans Up, THEN is Shunned by Family

An interesting letter appeared in the advice column Dear Abby on 11/30/14:

DEAR ABBY: I am a former drama queen and addict now enjoying long-term sobriety, or trying to. What's missing in my life is my family. Since returning from rehab, I have been "going it alone" -- and I'm not sure why. My kids are the only grandchildren in the family. I work and go to school. I am pleasant. There have been some rough spots I have had to deal with, and when I have needed to, I have called my mom or sister, but they don't call me or visit. They have expressed no love for me through all of this. When I call, I feel like I'm intruding. Aren't I entitled to their love and caring? I feel abandoned. It's hard doing things on my own. My family lives close by, so distance isn't the issue. What am I missing? I want my kids and me to have a family, but when I try to reach out, I end up hurt by their lack of interest. Should I just get on with my life? I have been going through this for years. -- MOVING ON IN FLORIDA

DEAR MOVING ON: It's possible that the "drama" and turmoil you put your family through while in the throes of your addiction is the reason your mother and sister avoid you. They may be reluctant to take a chance again. Because they have made it plain that they aren't interested in a closer relationship with you and your children, you should absolutely get on with your life.

Abby's response was predictable. There were also several comments on the website from the public about the letter, and the commenters were more or less unanimous: the letter writer had probably "burned her bridges," the family probably got sick of giving her one chance after another and were burned out, etc. etc. 

After all, as another commenter opined, "
Addicts hurt a lot of people and cause a lot of problems." The family's response is due to their need for "self preservation." The writer probably used to call them "only when she needed something."

These responses were in fact so predictable that the letter writer herself undoubtedly knew what she was going to get. She was setting herself up, and making herself look bad while all the while criticizing her poor family. The criticisms of the family did not go over well at all with Abby's readers. With her criticism the writer was in fact garnering sympathy for her family, rather than making them look bad. She had to know that would happen.

The burning bridges thing probably contains an element of truth. But more likely a half truth.

How did this former drama queen/addict turn out the way she did in the first place? Wasn't she in fact raised by the very family that is now shunning her? How many chances did they give her before giving up on her? When she was actively using did they get involved with her over and over again?  Enable her? Try to "rescue" her?

Notice that she identifies herself as a former drama queen. Where did that label come from? Is that what everyone in her family would call her over and over again until it became a role she would play in order to confirm their opinion of her? 

Was she in fact the only one in the family who had been expressing feelings that everyone else was stuffing? Was she the identified patient, as  family systems therapists call such folks, who gets all the blame for a problem shared by the entire family?

And most importantly, did they abandon her only after she cleaned up?

Inquiring minds want to know the answers to these questions before passing judgment.

This is a counter intuitive way to look at this. I understand that. But when the whole story comes out from patients in therapy, the answers to my questions are often yeses. Respected interpersonal theorist Lorna Smith Benjamin describes an analogous dynamic in which she lists two of the four characteristics she has observed in families that produce offspring with borderline personality disorder (BPD) - who often share many characteristics with both drama queens and addicts:

1. Parental love and concern is elicited only by misery, sickness and debilitation

2. Family chaos - The borderline individual is subtly blamed for problems or expected to exert control over them.

(The other two characteristics:  3. Episodes of traumatic abandonment are interspersed with periods of traumatic over-involvement, and 4. Efforts by the person with borderline disorder to establish autonomy are interpreted by the family as indicated disloyalty).

What may be happening in the case of the letter writer is that her family needs a black sheep, and she was elected to play the part. Because she finally stopped playing the part, they then shun her. In this situation, they would be in effect be punishing her for not being who they need her to be. However, they would also be helping her out in a strange way - by protecting her from their own pernicious presence. As Dr. Benjamin has also said, pathological behavior can be a gift of love.

This could be the real answer to the letter writer's question.

Monday, December 22, 2014

Increasing Placebo Responses in Psychiatric Drug Studies

In 2013, authors Rutherford and Roose  [American Journal of Psychiatry, 170  (7),  723-733] wrote a paper that discussed the results of a previous study that had found that the placebo (inactive "sugar" pill) response rates in random clinical trials (RCT's) of antidepressant medication had risen at a rate of 7% per decade over the past 30 years. Consequently, the average difference between active medication and placebo observed in published antidepressant trials decreased from an average of 6 points on the Hamilton Rating Scale for Depression (HAM-D) in 1982 to only 3 points in 2008.

Now the lead author of that paper and his colleagues have found something similar going on in RCT's between 1960 and 2013 of anti-psychotic medications for schizophrenia (the findings were published on line in October in JAMA Psychiatry). Most interestingly, in the 1960's, patients who received the placebo in such studies actually got worse on them.  By the 2000's, however, they were getting better on placebo.

Even more striking, the average RCT participant receiving an effective dose of medication in the 1960s improved by 13.8 points on the Brief Psychiatric Rating Scale (BPRS), whereas this difference diminished to 9.7 BPRS points by the 2000's.

What the heck is going on here? Are the medicines somehow becoming less effective than they used to be?

In their article from 2013, Rutherford et. al. try to explain this by looking at such things as expectancy (what do subjects think is going to happen with their symptoms), a statistical phenomenon known as  regression to the mean (see this post for a definition), the amount of contact subjects have with the study doctors, the social desirability of certain responses, and the “Hawthorne Effect” (subjects in an experiment improve or modify the aspect of their behavior under study simply by virtue of knowing that the behavior is being measured).

While the expectations of the average John Q. Citizen that antidepressants will work may have increased somewhat over the decades because of such things as celebrities describing their experiences with depression or commercials for Cymbalta and Abilify, there has also been a lot of negative information on that same score on television shows like Sixty Minutes and from the anti-psychiatry rants of Scientologists and others.

Whether these two influences completely cancel each other out is debatable, but I think it is safe to say that many of these possible reasons for a change in placebo response rate advanced by authors have in fact not changed significantly since the 1960's. In fact, if people in the 60's didn't think antidepressants would work, expectancies would have been lower, not only in the placebo group, but in the active treatment group as well.

If certain factors that affect placebo response rates have not changed a lot, then those factors can not explain the rise in the placebo response rates

The authors also mention a couple of factors that I believe to be more on the mark: first, that assessments of eligibility for a clinical trial may be biased toward inflated symptom reporting at the beginning of the study - when investigators have a financial incentive to recruit patients - and second, that most research participants in the 1960s and 1970s were recruited from inpatient psychiatric units, whereas current participants are symptomatic volunteers responding to advertisements.

The biggest change in research with RCT's over the period in question is that many studies are no longer done in medical schools, but by private entities called Contract Research Organizations (CRO's). The doctors who run the studies are paid for each subject they recruit, and subjects only get paid if they are recruited. This means that there are not just one set of financial incentives for everyone to exaggerate their symptoms at the beginning of a study, but two! This tendency will lead to a higher placebo response rate because after they are recruited, subjects no longer have an incentive to exaggerate their symptoms. So they seem to get better.

It is very easy to bias a research diagnostic interview. I'll get to that in a minute, but first a digression.

I was fortunate to train at a time when patients could be kept in the hospital for several months if necessary, so we got to see the patients in depth over a considerable time period, and could watch medication responses. People who have trained more recently do not see this any more.  Antidepressant responses clearly took a minimum of 2 weeks  - and then only if the patient responded to the very first drug given at the first dose given.

Because most patients do not understand this, the doctor can usually discriminate a placebo response from a true response by observing when the patient starts to get better combined with the rate at which they improve. Since subjects don't know what to expect, being on this timeline could not be due to the expectancy factor, which in turn is necessary for a having a good placebo response.

I can tell you that a severe, properly diagnosed melancholic depression almost never showed a significant placebo response.  The placebo response rate was probably about the same as the placebo response rate to a general anesthetic.

Another thing we observed was that patients with an acute schizophrenic reaction did not seem to get any better at all with such things as additional contact with doctors, which might be expected if a placebo response were taking place. In fact, the more you spoke with them, the more likely it would be that you would hear evidence that patients had a significant thought disorder than if you just had a briefer, casual conversation with them.

A thought disorder is at least as important as delusions and hallucinations in showing that someone is, in fact, someone with schizophrenia. People with a thought disorder see relationships between things that are completely illogical (loose associations). For example, the first patient I ever saw with schizophrenia in medical school believed that everyone who wore oxblood-colored shoes was a descendant of George Washington.  


Anyway, back to the question of biasing diagnostic exams. This is particularly easy when diagnosing a clinical depression. It is important to distinguish them from those people who are merely chronically unhappy.  People with a clinical major depression, especially with so-called melancholic features, are a very different breed of cat.  

The  symptoms of both disorders do overlap a bit, so there are some cases in which it is really hard to tell one from the other. However, in the majority of cases it is a fairly easy call. It is, provided you do a complete psychiatric assessment, over several days, to see if a symptom of depression meets the requirement known as the Three P's: 

The symptoms need to be pervasive (they do not go away depending on what the patient is doing at a particular time), persistent (lasting almost all day every day for at least two weeks), and pathological (the patients symptoms and functioning differ to a highly significant degree from the patient's usual state). In addition to the three p's, all of the patient's symptoms have to always occur simultaneously.  

These types of characteristics do not usually show up on the type of symptom checklists used to assess patients in clinical trials, because the checklists are mostly based on a patient's self report.  Unfortunately, the majority of people do not know the difference between a clinically significant symptom and one that is not. The rate of false positive responses on checklists is staggering.

Many studies instead use something that is called a semi-structured diagnostic interview (such as one called a SCID) to make a diagnosis. It is called semi-structured because it tells the examiner to ask certain questions exactly as they are posed verbatim. However, the examiner is then free to ask any follow-up questions needed to clarify the clinical significance of any symptom the patient reports.

If you want to diagnose major depression regardless of whether or not the patient actually has it, all you have to do is accept every "yes" answer a patient gives to a question about a symptom without any follow-up questions to see if the symptom is characterized by the three P's. If the patient answers "No" to a question, however, you keep pumping the patient for additional clarification until you can find something the patient says that will justify changing the "no" answer to a "yes."  Voila.

Friday, December 12, 2014

Book Review: Ghost of My Father by Scott Berkun

Half of all profits from this edition of Mr. Berkun's book, Ghost of Our Fathers (Berkum Media, 2014) will be donated to Big Brother Big Sisters of America

Our parents, or our primary caretakers when we were growing up, have a profound effect on us for our entire lives. They have this effect whether they like or not, and whether we like it or not. Attachment research has shown that their interactions with us help shape our mental models of both the world and how relationships are supposed to operate under various environmental contingencies (schemas).

The part of the brain called the amygdala, central to our fight/flight/freeze reactions to fearful stimuli, has specific cells that respond only to the face our mothers (or primary female attachment figures) - and nothing else. It also contains cells that respond only to our fathers/male attachment figures - and nothing else.

Even those who have managed to become more self-actualized or differentiated from our families of origin - who can follow our own muse and live according to our own independently formed beliefs - still hear or feel those old tapes of our parents' admonitions whenever we do things of which our parents routinely disapproved. I know I do, and my parents have been gone for decades. We can choose to ignore these tapes, but there is often a nagging doubt that arises in our minds whenever we do.

In his new book, Scott Berkum describes a feeling of being haunted by the past as well as by the ongoing behavior of his father, and does so eloquently using the words of a poet. I'll mention some examples of his beautifully-worded descriptions of some of the phenomena discussed previously this blog shortly.

Most of what I have written about dysfunctional family interactions on this blog as well as my blog on the Psychology Today website concerns what happens when parents give us contradictory or mixed messages about what is important to them, as well as what they expect from us. But what happens when they seem to give us almost no signals at all? When the parent is a big cipher? This is what happened to the author in his relationship with his father, and I suspect, though to a much lesser extent, with his mother.

His father was gone much of the time during his childhood, spending most of it working or at the racetrack gambling. He completely abandonned the family and the patient's mother twice in order to have extended affairs - once when the patient was eight years old, and once when the patient was in his forties. And yet when he returned each time, the mother would want him back, take him in, and take care of his needs.

He seemed to have little interest in what was important to the author. Much of the time he seemed to barely acknowledge his son's presence. The only sustained interactions they had seemed to occur at the dinner table, when the author, his siblings, and his father  would debate political and social issues. Father would seem to purposely take up a provocative position on the issue, and then stick with it no matter what arguments the author came up with.  Dad would never concede a point.

The author was plagued thoughout his life with a feeling that he was unworthy of his father's attention, and that nothing he did mattered to his Dad.

The author tried on numerous times to do what I recommend to my patients in therapy: attempt to empathically confront Dad to try to find out what made him tick and what he was really thinking (metacommunication). Unfortunately, each time he tried he ran up against a brick wall that would never come down. His father seemed to be incapable of discussing feelings. If the author pressed forward anyway, the conversation would devolve into a shouting match.

The book does not describe what was said during these explosions. With my patients in therapy, I try to obtain a blow-by-blow description of exactly what was said,  in chronological order, as best the patient can remember. This often gives hidden clues about the emotional processes that are taking place in both participants during the battle, as well as to why they are reacting the way they are.  In turn, this can suggest ways to have conversations that do not go in the usual direction and do not become fighting matches.

Interestingly, Dad did apologize for his behavior on one rare occasion and even expressed his love, but both the apology and the expression seemed to ring hollow with the author, who more or less rejected them.

Of course, when the author rejected them, he may not have realized that this let his father off the hook as far as further elaborating on the problem at hand- which was likely the father's goal all along. Saying what a family member wants to hear in a seemingly insincere way and/or when it is least expected often leads to such a rejection of the expressed sentiment. The person who does this then walks away thinking, "Just as I thought - he didn't really want to hear that, but at least I tried." This is an example of the game without end.

The author does discuss some genogram information, although whatever therapists he saw may not have not called it that nor known exactly how that information might best be used to design more productive family interactions in the present. The information about his father's upbringing was rather telling, and seemed to explain one statement the father made in the middle of one of the author's attempts to metacommunicate: "Your problem is you remember too much."

The author's paternal grandfather was described as "the quietest man I ever met." The author adds that he "...was always watching professional wrestling when we visited. He'd stare into the television as if he and it were the only thing left on the planet. His social skills, even with his own grandchildren, were non existent...I don't remember him ever saying a word to me."

No doubt Dad's father had done to him pretty much what he did to his own son. 

Clearly this was Dad's unfortunate role model for being a father. Clearly there was a family rule against fathers and sons communicating meaningfully. The author also admits that he shared some traits with his father - at times more than he cared to admit even to himself - demonstrating the intergenerational transfer of dysfunctional traits. The father must have tried to handle his own feelings by trying to "forget" what had happened.

A clue as to the origin of the family rules is that the father's paternal great grandfather  fled to the US from Ukraine in 1902 to avoid being drafted into the army, leaving his brothers behind. Undoubtedly there was a lot more to that story, especially since the brothers died in the Holocaust many years later. Was there some resulting hidden guilt and shame that had to be kept out of mind and never discussed?

The book is supposed to be primarily about the author's relationship with his father, so Mr. Berkum gives limited attention to his relationship with his mother. While he described them as close, it sounds as though certain subjects were off limits with her as well - like why she remained involved with such a distant man, and why she would take him back after a second betrayal.

The only person in the family who seemed to be able to express anger was the author's sister Tracy, who of course went overboard in doing so. Interestingly, the parents seem to keep her around almost as a pet - she lived with them or next door to them even after she married and had kids - until she, like the author himself did as a rather young man, finally moved away to escape. 

No doubt the parents needed Tracy's expressiveness to release some of their own pent-up rage.

Some concepts from the blog that the author describes poetically:
Distancing: "He mastered wounding us just enough that we'd leave the conversation as quickly as we could." (p. 11).

Existential groundlessness: "...we forget when we become adults that the armor made to survive our youth no longer serves us...yet removing it is puts us at odds with our family and friends, as tribes prefer to stay with patterns of the past. Most people convince themselves that removing their armor is something they don't need to do. And their families, complicit in the same denial, reward the defense of the status quo, ensuring the...same armor, and the same ghosts, will be passed on to the next generation..." (p. 17).

The power of family ties"It is curious, perhaps even strange, that the choices of my father would impact me so profoundly at forty years old." (p. 22).

"I didn't realize that just because you're done with the past doesn't mean the past is done with you."

Mutual role function support: "Each person needs the other badly, in the way an alcoholic needs another drink. When one takes a drink of the feels good. It covers certain holes, allowing them, in moments, to be forgotten, but does not fill them. My mother and father love each other for that feeling, and hate each other  for the same reason." (p. 114).

On the feeling of not counting for his father, after a brief encounter after he returned late from the racetrack:  "It was the bottom of the barrel of his day..." (p. 150).

I could go on. This book is a brutally honest memoir, well worth reading.

Tuesday, December 2, 2014

Intrapsychic Conflict and Dysfunctional Family Patterns

There have not been a lot of studies done looking at how personality problems affect individuals over three generations within a family, and how they may be passed down from one generation to the next. Today’s emphasis is studying mostly biogenetic factors.

However, the few studies that have been done generally show the same types of things. Although there is never a one to one correlation (because people’s development is affected by the chaotic interactions of thousands of different variables – genetic, biological, interpersonal, and sociological), certain issues are highly likely to be passed down.

Earlier studies have shown what is known as intergenerational transfer of certain types of dysfunction for, as examples:

  • Boundary disturbances such as maternal overprotection and relationships characterized by lack of affection, enmeshment, and/or parent/child role-reversals (Jacobvitz et. al., Development and Psychopathology, 3, 513-527, 1991).
  • Emotional dysregulation with poor disciplining skills with children (Kim et. al., Journal of Family Psychology, 23(4), 585-595, 2009).
  • Substance abuse with parental substance abuse combined with abuse and/or neglect and low levels of family competence (Sheridan, Child Abuse and Neglect, 19 (5), 519-530, 1995).

In understanding this process, I try to incorporate concepts from different "schools" of psychotherapy. The most important task in integrating different psychotherapy models is to pose the question of how concepts from different therapies might relate to one another, and how slight modifications to specific aspects of these concepts may make relationships between them more clear.

In this post, I will focus on the relationship between several such concepts. We have the concept of intragenerational transfer of dysfunctional behavior from Bowen family systems therapy. Then we have a primary concept from psychodynamic therapy, intrapsychic conflict. People have conflicts between their innate desires and the values they have internalized as they grew up within their family and culture. 

To see how these two concepts can both be valid and also when combined explain certain human behavior, we can take a closer look at the intergenerational transfer question.

The attachment theorist Bowlby first suggested that these transfers occur, not through specific observable behaviors like “abusiveness” or psychiatric diagnoses per se, but through the generation of mental models of interpersonal behavior in the affected children. These working mental models are now called schemas by both psychodynamic and cognitive-behavioral therapists. They are also subsumed under the rubrics theory of mind or mentalization by another set of psychodynamic therapists. We need to look at the subjective experiences of the involved children throughout their development.

Zeanah and Zeanah (Psychiatry, 52, 177-196, 1989) discuss the concept of organizing themes. They mention that studies show that abusing mothers tend to attribute more malevolent motives to their own children compared to other people’s children. More generally, they react with more annoyance and less sympathy to videotapes of crying infants than do non-abusive mothers. To think that these patterns would not be noticed or sensed by children through their daily interactions with their parents, and would not affect the development of their schemas, would be extremely naïve.

In turn, abusive mothers reported more threats of abandonment and role reversals with their own mothers than did control mothers.

These findings are probably the tip of the iceberg in terms of subtle characteristics of repetitive parent-child interactions, and as the Zeanahs say, “Patterns of relating are considered to have more far-reaching consequences than specific traumatic events” (p.182).

When Bowen therapists started doing the genograms of their patients, which describe family interactional patterns over at least three generations, they noticed something that has not really be described much in empirical studies. While some children of dysfunctional parents had problems that were similar to their parents -  such as substance abuse - other children seemed to have developed behavior patterns that were exactly the opposite – they became teetotalers!

I have seen this sort of thing many times in taking genogram-related family histories from my own patients. One son of a workaholic will also be a workaholic, while his brother becomes a complete slacker who can’t seem to hang on to a job, or who does not even bother to look for one and goes on disability of some sort. Or who is enabled by the workaholic father.

In fact, in some families one generation has a lot of alcoholics, the next generation a lot of teetotalers, and the third generation goes back to having a lot of alcoholics. Or impressive successes in one generation are followed by remarkable failures in the next. McGoldrick and Gerson, in their book Genograms in Family Assessment, traced the genograms of some famous people like Eugene O’Neill and Elizabeth Blackwell and readily found such patterns.

If these sorts of issues were entirely genetic, it would be difficult to explain how progeny of the same parents could be so completely opposite from one another, as well as completely opposite from their own parents. So what might be going on psychologically within people that might lead to interpersonal behavior with their own children that generates such bizarre patterns?

This is where intrapsychic conflict may come in. Say a father was a young adult during the Great Depression of the 1930’s. He had grown up feeling that work defined him, and that he was obligated to keep his nose to the grindstone in order to support his family. He was lucky enough to have a job, but his boss made his life miserable. He could not quit because he would not be able to get another job, and therefore he began to subconsciously resent the very values with which he has defined himself.

This could lead him to develop an intrapsychic conflict over hard work which starts to tear him apart. He may relate to each of his sons in a manner that – very subtly - suggests to one son that he too should be just like him, while the other son is subtly rewarded for acting out the father’s hidden resentment towards hard work and self-sacrifice.

Likewise, a patient might come from overly-strict religious parents who had rejected any and all hedonistic pursuits, but who had preached to their child about the evils of alcohol in a highly ambivalent manner. Such ambivalence usually arises in them because of their having received mixed messages from their own parents. Their son may feel pushed to rebel, and therefore lead a licentious, alcohol-drenched lifestyle. Such a person often destroys himself in the process, because if his parents observe him being successful in spite of drinking, this would exacertate the conflict in his parents and destabilize them. This would frighten him. So he becomes a self-destructive alcoholic.

His behavior would be sort of compromise. He would be following the repressed urges of his parents and allowing some expression of them, while at the very same time showing his parents that repressing the urge was indeed the way to go.

In the next generation, his children may “rebel” just like he did, but the only way they can do so is by going to the opposite extreme themselves. They become teetotalers. Their children, in turn, “rebel” by becoming alcoholics.

I’m tremendously over-simplifying this process so the basic outline is clear to the reader, but I see these types of patterns – with many fascinating twists and turns - every day in my practice.

Friday, November 21, 2014

Dumb Hidden Assumptions in Drug Abuse Research

The mental health professions these days seem to want to blame their patients' repetitive problematic or self-destructive behavior on just about anything except what is, in the large majority of cases, the primary causes: family dysfunction and adverse childhood experiences (ACE’s). And I mean, they would rather it be almost anything else.

In my post of February 26, 2011, I discussed how a slight increase in aggressive thoughts following the playing of violent  video games by adolescents was translated by researchers into the games being a major risk factor for the development of youth violence. The fact that most compulsive video game players are inveterate couch potatoes who do not get out much never entered into discussions.

Not surprisingly, a recent longitudinal study (Fergus0n et. al., J. Psychiatr Res 2012; 46: 141-146), showed that, by taking other variables into account such as intra-family violence, the correlation between video games and even short-term aggression could no longer be established.  Another older paper from the same lead author (Ferguson and Rueda,  J Exp Criminol, 2009; 5:121-137) showed that aggressiveness in the laboratory, as expected, did not correlate with violent acts in real life.

Focusing on minor targets like video games risks leading social activists and public policy makers to ignore the far more important causes of youth violence like child abuse.

So of course, now that the tide is turning against the insane drug war against  marijuana, which has turned a significant percentage of the population into criminals (who tend to only be prosecuted if they happen to be African American), the folks who refuse to look at reality are now publishing "studies" that attribute a host of problematic behavior almost entirely to the devil weed – while all the while making the most ridiculous hidden assumptions imaginable. 

People who feel the need to be stoned all the time have enough problems; we do not need to make up a bunch of other ones.

In Carl Hart’s book High Price , he recounts his adventures as a reviewer of potential drug abuse studies for funding from the National Institutes of Health. He mentioned that the research agenda was being controlled by the National Institute on Drug Abuse (NIDA). He makes it clear that they were only interested in studies that showed the dangers of street drugs, not on studies which countered the many myths in the field that he had described in the rest of the book. (NIDA also ignores the dangers of the very same drugs they demonize when Pharma sells them for conditions such as "ADHD").

Now comes a study out of Australia and New Zealand: “Young adult sequelae of adolescent cannabis use: an integrative analysis” by Edmund Silins and others. (Lancet Psychiatry, 2014;
1: 286–93). Here is the abstract:

Methods: We integrated participant-level data from three large, long-running longitudinal studies from Australia and New Zealand: the Australian Temperament Project, the Christchurch Health and Development Study, and the Victorian Adolescent Health Cohort Study. We investigated the association between the maximum frequency of cannabis use before age 17 years (never, less than monthly, monthly or more, weekly or more, or daily) and seven developmental outcomes assessed up to age 30 years (high-school completion, attainment of university degree, cannabis dependence, use of other illicit drugs, suicide attempt, depression, and welfare dependence). The number of participants varied by outcome (N=2537 to N=3765).

Findings: We recorded clear and consistent associations and dose-response relations between the frequency of adolescent cannabis use and all adverse young adult outcomes. After covariate adjustment, compared with individuals who had never used cannabis, those who were daily users before age 17 years had clear reductions in the odds of high school completion (adjusted odds ratio 0·37, 95% CI 0·20–0·66) and degree attainment (0·38, 0·22–0·66), and substantially increased odds of later cannabis dependence (17·95, 9·44–34·12), use of other illicit drugs (7·80, 4·46–13·63), and suicide attempt (6·83, 2·04–22·90).

Interpretation: Adverse sequelae of adolescent cannabis use are wide ranging and extend into young adulthood. Prevention or delay of cannabis use in adolescence is likely to have broad health and social benefi ts. Efforts to reform cannabis legislation should be carefully assessed to ensure they reduce adolescent cannabis use and prevent potentially adverse developmental effects.

Funding: Australian Government National Health

The authors claimed to control for confounding variables, but most of these "controlled" variables were unrelated to ACE’s or ongoing family chaos. They were such things as age, sex, ethnicity, socioeconomic status and mental illness. The authors did control for a few possibly relevant parental variables like alcohol use, tobacco use, divorces, and history of depression. But not for how the parents actually behaved around their children, how they treated their children, child abuse or neglect, how chaotic the home environment was, or how and how consistently the children were or were not disciplined.

What on earth makes people who draw the conclusion that the drug was the primary cause of the lower achievement become so stupid that they don't see that frequent drug use is a sign that the teens already had emotional problems before they even started smoking - and that it was these problems that predate the drug use that were the real cause of both the drug use AND the poor performance?

The authors used exactly one rather vague sentence in their discussion to refer to this possibility, which most readers will miss: “…cannabis use in adolescence could be a marker of developmental trajectories that place young people at increased risk of adverse psychosocial outcomes.” (p. 291). 

Ya think?