Wednesday, April 1, 2020

Family Dynamics and the Brain: Implications for Psychotherapy

IMO, the most important contribution of neurobiology to psychotherapy is our understanding, albeit quite partial and preliminary, of the mechanisms by which we are programmed to respond to attachment figures. This understanding is sort of what is meant by sociobiology, if I may use a politically incorrect term. 

I found early on in treating personality disorders in therapy that I was no match for a patient’s parents in triggering or reinforcing their problematic (or even their positive) behavior patterns in the long term. I could coach them on how to be assertive with difficult family members ‘til the cows came home, and this might even work for a time, but after a while the old patterns of self-defeating behavior almost invariably re-emerged unless something was done about this.

Even so-called “oppositional” behavior follows this path: oppositional children think and later automatically respond to their family as if the family wants or needs them to be a black sheep for various reasons.

Therapy outcome studies seldom follow patients with self-destructive or self-defeating behavior patterns for more than a year after therapy ends, but the few studies I’ve seen that do are consistent with this clinical experience. So I had to figure out a way to help patients to make changes in their long term repetitive dysfunctional interactions with attachment figures.

When mothers and their babies interact, huge numbers of synaptic connections in the brain are made every second (see These large numbers are “pruned” significantly during adolescence. We don’t know exactly how or why certain synapses are retained, but I suspect it is those that keep us aligned with the social behavior of our kin group and tribe. There is preliminary evidence that the pruning is dependent, much like the strength of many brain neural connections, on how often a particular neural pathway is stimulated.

Another factor involved is something called the myelination of neurons in existing neural pathways. This is the process of coating the body of each neuron with a fatty coating called myelin, which protects the neuron and helps it conduct signals more efficiently. This process does not become complete until an individual reaches late adolescence.

With these two processes, we lose some flexibility in the brain, but the proficiency of signal transmission improves. Since we are talking in particular about those that form during interactions in infancy, it is reasonable to suspect that these interactions continue to do this. In particular, behaviors that occur in response to social cues may become more automatic in order to preserve higher thinking ability for novel situations.

In addition to this, fear tracks formed early in life in particular are not as plastic as are other tracks in the brain. They never really go away, although they can be overridden by newly formed neural pathways. (Lott, D. A. [2003]. Unlearning fear: calcium channel blockers and the process of extinction. Psychiatric Times, May, 9-12).

According to Neuroscientist David Eagleman on his PBS show, The Brain, about 80% of our behavior is done automatically in response to environmental cues (especially social cues, I might add) without any conscious deliberation. In a sense they are subconscious.

This does not mean that we lack the capacity to decide to think about and break the social rules we are usually bound by. We certainly can – this is where the family systems theorists have been wrong. But when we do, we are often faced with massive invalidation by our families, which is extremely powerful in delivering the message, “You’re wrong, change back.” When we distance ourselves from our social alliances, our level of the attachment hormone oxytocin dips and we start to feel unsafe.

The negative feelings generated by this invalidation is probably the biological price we pay if we don’t: the highly disturbing feeling of groundlessness described so eloquently by Irvin Yalom. This is nature’s way of telling us to behave ourselves for the good of our kin group. This has survival value for the group.

The implications for therapy are clear. In order to prevent problematic automatic behavior patterns that have been and that are continually reinforced through this powerful process, neither insight into which behaviors are performed automatically, nor which automatic belief systems keep us on the straight and narrow for our kin group, is usually enough. These patterns need to be interrupted at their source in order to help patients extinguish bad habits of thinking (or, more often, not thinking) and behavior. 

Tuesday, March 10, 2020

P.C. Feminism and the Misinterpretation of Attachment Theory

Some feminists hate attachment theory. Their influence may be part of the reason so many psychotherapists ignore its important implications. Attachment theory is a set of ideas based on the theories of psychoanalyst John Bowlby and strong experimental evidence created by Canadian psychologist Mary Ainworth. Ainsworth was of course herself a working woman, although she was divorced and never had children of her own.

Ainsworth sat behind a two-way mirror for years and watched one-year-olds playing with their mothers. She noted what happened when the mother left the room for a few minutes and how the child responded when she returned. She then took the study a stage further and studied what happened when, instead of the mother, a stranger entered the room and tried to engage with the child. Ainsworth's "Strange Situation" study, together with Bowlby's theory, showed that how a child developed their social response patterns was the direct result of the way the child's main carer responded to and engaged with them. 

A neglectful, stressed or inconsistent parent tended to create an anxious, insecure or avoidant children. These patterns were later found to accurately predict how those children behaved between the ages of five and eight.

Feminists argued: watching babies - what kind of proof is that? How can anyone know what a baby is thinking and feeling? Isn't it all just woolly liberal conjecture? Gee, actually observing what is going on and seeing the same patterns over and over again. Why, isn’t that anecdotal? Unlike, I suppose asking research subjects to tell you what they are thinking. Now that’s objective data!

They accused attachment theorists of being against working women and wanting to shackle women to the home. I guess that they thought the implications of the theory were that women needed to be home 24/7 or they would destroy their children. Shades of evolutionary psychologists attacking anyone who dared study or even talk about kin selection, the tendency of human individuals to sacrifice themselves if their kin group or tribe seemed to require it, because it might be used to justify social Darwinism. Well, I guess it could be used that way, but it certainly does not have to be.

Even if the attachment science actually did prove that it is far better for children to have stay-at-home mothers, that would not mean inconvenient realities should be ignored. But luckily, it doesn’t that at all! Unfortunately, even the purveyors of attachment theory often misinterpret the data from Ainsworth’s experiments, due to a logical error and a phony assumption. Ainsworth herself was skeptical about the viability of working motherhood, but, unlike Bowlby, admitted the possibility that supplemental mothering could be arranged without harm to the child.

The logical error is equating quality with quantity. Just because a little of something is a good thing, this hardly means that a whole lot of it is even better. Sometimes a lot is worse! The dose makes the difference between a nutrient a poison. It is not how often the mothers in the experiments interact with their babies, it’s the type of interactions. Maybe the kids also need to start having time by themselves as well as time with other children learning how to deal with them.

The false assumption is that the data that shows that the early patterns predicted the later patterns must mean than any “damage” done to the child’s brain must be permanent. That would of course mean that human beings could never adapt to new social contingencies, something that is clearly nonsense. Our species would not have survived if adaptation were not possible after the age of two!

This interpretation of the experimental findings ignores the fact that the five to eight year olds are continuing to be exposed to the exact same problematic parenting behavior which had triggered and reinforced the earlier behavior. Shades of the bullshit about cognitive development I posted about in my review of the book The Myth of the First Three Years.

What about the “strange situation” phenomenon? Well, the limits of the data are clearly implied in its name. This is what happens when a complete stranger enters the picture, not a familiar adult from, say, a day care center or a Kibbutz in Israel.

Many (but hardly all) children from abusive homes who are adopted out to loving families do indeed continue to show the effects of the earlier trauma, but that does not mean that earlier physiological changes are irreversible. The fact that some children do in fact get much better while others continue to have problems is most likely due to the behavior of the adoptive parents. 

They may not know how to deal well with the obviously difficult behavior of these children and so may inadvertently continue to feed into these children’s problematic behavior. It is not at all obvious how to respond to disturbed kids, and even if you know how, doing so consistently in the face of frequent child misbehavior (which is key) is tremendously challenging. Others may have learned what to do about it and stuck with it – maybe just from watching the TV show Supernanny – and voila, the kids become well adjusted.

In fact, children benefit tremendously from having a happy, fulfilled mother who isn’t feeling guilty. I’ve written extensively about my contrary-to-the-popular-wisdom understanding about how children learn to read their parents' behavior. (Speaking of Supernanny, there was a recent episode in which a father wondered why his son said he thought his Dad liked to clean the toilets at home. The son answered, “Because you do it all the time.” That’s what I’m talking about!).

Human babies are born wired for survival. We are wired to learn how to survive through interacting with other people. Throughout life.

Thursday, February 27, 2020

Parental Guilt: a Double Edged Sword Inside a Conundrum

When I write about dysfunctional family dynamics on my blogs, in response I often get parents and adult children reacting in completely opposite ways to the very same post: the parents think I am putting the blame all on them, and the adult children likewise feel I’m singling them out. Of course, the parents had the issues that are creating difficulties before the kids ever came into existence, so this makes them somewhat more responsible, but they are reacting to binds that they themselves were put into by their own  parents. In turn, their parents were reacting to their parents, and so on.

Of course, when people feel blamed for something they don’t really like, but sort of know they had something to do with, they tend to feel guilty, which tends to make them defensive. Defensiveness, in turn, causes them to tune out discussions of what they might be able to do differently in order to fix the family problem. That would be bad enough, but there is something else that amplifies this problem even more. The fact that they felt guilty even before reading my stuff is often the main problem that caused them to give off destructive double messages to their kids in the first place.

The women’s movement was great in terms of opening up fulfilling opportunities for women for which they are more than qualified. However, it also a big factor in creating a lot of parental guilt as when both parents are working, this has made many of them feel like they are neglecting their kids. As I have written, the Phyllis Schlaflys of the world pile on the guilt. This cultural argument has two effects on the parents: anger at their kids for complicating their lives, and attempts to make up for their frequent absences by overindulging their kids and trying to be friends with them.

The latter behavior creates all the issues that parenting columnist John Rosemond has been writing about for years: it makes the kids feel inadequate. My view on this is slightly different than his: I think the kids start to believe that the parent’s constant need to cater to them is evidence that the parents need to be caretakers to remain mentally stable, so the children start to act as if they are inadequate so the parents can continue to feel needed.

If the parents’ anger predominates, this can lead to acting out by the child to provide the parent with a feeling of justification for being angry and therefore not as guilt-ridden.

If the parents go back and forth between compulsive caretaking and anger, the child develops one of the major characteristics of borderline personality disorder: spoiling behavior. When the parent gets too angry the child tries (and usually succeeds at) making the parent feel guilty, but then when the parent feels too guilty, the child finds ways to make them angrier.

Because the issue of parental guilt is so central, this creates a conundrum for anyone trying to get the family to discuss what is really going on so that it can be stopped or at least minimized – including any family member attempting to do this, a therapist trying to help the family, or a writer of blogs trying to get people to focus on real issues rather than looking for scapegoats or facile explanations for the self -defeating behavior of family members. When any of these folks bring up what the parents are doing “wrong,” this tends to make the parents feel even guiltier, which is the source of the problem in the first place. The problem then gets even worse rather than better.

When I had such a parent in therapy, I was able to find a way to finesse this, by discussing how their child may be mis-reading them, which tends to be a less guilt-inducing way to put it. Also, I can empathize with the bind that the parents are themselves feeling, having formed a preliminary hypothesis about why their own parents acted as they did.

This is much more difficult to accomplish when writing for the public, because readers tend to quickly focus more on anything that seems at first glance to be less than empathic with their own plight. I do talk about how the problems have been passed down from prior generations, so if we have to blame anyone, let’s blame Adam and Eve and be done with it. I also make use of a great quote from John Rosemond: "Taking responsibility for something and self-blame are horses of two entirely different colors. The former is empowering; the latter is paralyzing." However, I can’t discuss these ideas in detail in every single post or they would all be twice as long as this one. And anyway, disclaimers like that are often ignored in the heat of the moment.

Tuesday, February 11, 2020

Spoiling Behavior is All an Act, But a Deadly Serious One

Relationships between people are formed through interactions that are two-way and simultaneous. People learn and become different over time as this occurs, and can push one another away.

I recently received an angry letter from a mother whose child apparently has been diagnosed with borderline personality disorder (BPD). She told me that I must have no idea what it is like to raise a child with the disorder, or I would never say what I do about it. She added that kids with the disorder do not respond to the most positive of upbringings, so don’t blame parents!

Having been the direct recipient of the spoiling behavior of adult patients with the disorder when I started out as a therapist - and did not know then how to deal with their in-session behavior effectively - I can say that I have a really good idea about what that is like. And it ain't no picnic. And I agree that unrestrained positivity does not change it. It can even make it worse!

It is also true that not all families that produce kids with the disorder are overtly abusive either physically, sexually, or verbally, although a large and significant majority of them are in fact abusive in those ways – according to every study ever done. Even DBT therapists believe they come from an “invalidating environment,” even though they seem to scrupulously avoid identifying that specific environment as the family of origin.

I would like to suggest that the reader take a look at what the letter writer said in a different way than would be a typical interpretation. (Of course, I can’t know for sure even if her child has even been correctly diagnosed or exactly how positive the family environment is). In just a couple of sentences, she could be understood to be saying that her parenting has nothing to do with how her child turned out. In a phrase, it is only the child who is (completely) screwed up.
If I’m hearing this in a short letter, you can bet that the child has heard it. And guess what? If children hear this point of view a lot, they will begin to act in ways that give the parent an easy justification for making the statement so the parents don’t have to feel bad about blaming everything on the kid. But doing this is all an act to placate and stabilize the parents.

I can predict relatively confidently that if the mother continues to exhibit this same attitude much of the time, the child will continue to give her grief, and will not get better.
Likewise, if a parent is constantly invalidating a child, the child will begin to act in ways that practically invite invalidation. One leader of a parents of BPD kids' support group once told me that her daughter said bizarre things, such as that she had grown up poor. The family was in fact quite well off financially. The daughter was not psychotic. Her mother is quite bright, so I would have to assume that the daughter is not actually stupid enough to somehow not know that the family was affluent. If she were my patient, I would ask her specifically what she thought the family was poor in. Validating responses, perhaps? Warmth?
When I speak of this stuff being an act, I always have to clarify that it is specifically the spoiling behavior which is the act. The way they generally feel, their sense of a poor identity, the impulsiveness and such are all real – but all adaptive or reactive to the family dynamics that produce BPD.

Monday, January 20, 2020

Are People Really as Stupid as they Often Act?

Einstein reportedly said that the definition of insanity is doing the same things over and over again but expecting a different result. In psychotherapy, we see a lot of self-destructive and self-defeating people who, by that definition, must be insane. Except they are not psychotic, so they are not acting this way because they are delusional. An alternate explanation: they are just too stupid to see how unproductive their chronic repetitive behavior actually is. If you are looking for evidence of stupid human behavior, it certainly is easy to find.

But are they really that stupid? I mean, if you step on something that causes a 2 X 4 to knock you in the face, you might miss the connection once or twice. But would you be oblivious to that if it happened repeatedly? Of course not! Even if you had an IQ of 70. So this raises the question, why do people persist in dysfunctional behavior if they really are not that stupid?

Readers of this blog will already know how I answer this question. If someone keeps doing the same things and getting the same results, those results are the ones they are aiming to get! A good way to determine what people are really going after in these cases is looking at what I call the net effect or end results of the behavior. Of course, people claim not to know why they persist even though it becomes painfully obvious when looked at in this way. But they are lying to you – as well as often lying to themselves.

In actuality, they are willfully blind to the consequences of their behavior. Or, some might say, they are in denial. But at some level, they have to know what they are doing. They just refuse to think about it. In fact, they are acting out a false self meant to stabilize unstable attachment figures. They are playing a role. They are literally acting. To be a good actor, you have to really believe you are the character you are playing, but at some level you know you are not (the actor’s paradox).

Another way to keep one’s true self from rising to the fore is to continually devalue it with irrational beliefs as described here

Some religions, while they clearly offer much comfort to many people, may also encourage beliefs that feed into people devaluing themselves. They do this in order to enforce group conformity and, when they deem it necessary, sacrificing oneself for the good of the group. For instance, some churches basically teach that in God’s eyes we are all reprehensible sinners, and that the only way to be saved is to do what the church leaders of that particular denomination tell you to do. They preach that you should put God first, your family second, and yourself last.

Monday, December 30, 2019

Mental and Interpersonal Mechanisms of Groupthink Maintenance

                                                                                          PatientSafe Network

This post is a shortened version of one of my chapters in the upcoming multi-author book, Groupthink in Science.

One of the defining characteristics of groupthink is something called “willful blindness.” People often know things but choose to pretend that they do not, in order to fit in with larger social groups. They lie to everyone including themselves They refuse to look at any sources of information that might call into question any beliefs that help them to “convey and conform to” the needs of the various groups to which they belong. The paradox of such willful ignorance is that in cases in which you are motivated to avoid looking at something, you have to know where not to look! In other words, you had to have seen it.

The reason that we all do this has to do with a significant characteristic of natural selection during biological evolution. Conforming to the values and requirements of our kin group or tribe has high adaptive value. Genes that contribute to the survival of the tribe or clan to which we belong, as opposed to those that only benefit individuals, are highly likely to be passed on. This process is known as kin selection.

While sacrificing oneself for a group – such as the widespread willingness to die for one’s country in a war – is not beneficial for individual survival, it does contribute significantly to group survival. Nonetheless, it can sometimes actually harm a group’s interests in the long run. The term pathological altruism has been used to describe situations in which this tendency to self-sacrifice backfires and harms not only the individual making the sacrifice but his or her group as well.

Many mental mechanisms and tricks have evolved to help us lie to ourselves to achieve these purposes. Interestingly, we also tend to assist our fellow group members in using these tricks on themselves. Groups as a whole also have a variety of mechanisms for keeping certain information censored. The mechanisms are the subject of this post.

They appear at the level of the individual, where they include the defense mechanisms described by psychoanalytically-oriented psychotherapists, and the irrational beliefs enumerated by cognitive behavioral psychotherapists. They also appear at the level of the family or kin group, where they are called family myths. They also exist at the level of cultural groups, where they are called mythology.

Defense mechanisms were originally defined as mental processes, typically subconscious, employed by individuals to avoid ideas or impulses that are unacceptable to their own personal value system, and to avoid the anxiety that those ideas or impulses therefore created. Notice, however, that these mechanisms do not just serve an internal purpose within our mind, but an interpersonal one as well. We may, for example, compulsively try to act in the opposite way that an impulse that is unacceptable to our group would dictate (reaction formation), or displace our anger at one person within our kin group onto another outside, safer person to avoid tension within our group.

Irrational Beliefs are often automatic in that they come to us without any conscious effort in response to an environmental event, and they quickly lead to specific behavior patterns. They are often said to be subliminal, which is a similar concept to subconscious. If you, for example, catastrophize (imagining every single thing that could possible go wrong if you did something, no matter how unlikely) about your engaging in a course of action not condoned by your group, you will indeed scare yourself away from engaging in it. Group norms are often internally policed by unquestioned thoughts that start with “I should or must” do or think this or that. If you had contrary thoughts in the past that turned out to be wrong, you might overgeneralize by thinking that all the thoughts related to the earlier ones are always going to be wrong as well.

Logical fallacies can also be used to either explain away or justify ideas that might contradict group norms or beliefs. For instance, post hoc reasoning assumes wrongly that if event A is quickly followed by event B, then it is probably true that A caused B. Therefore, you opt to avoid A in order to avoid B. An example: "Looking at pornography will lead to sex addiction." This is fallacious because the pairing is often due to another variable common to both A and B - in this case the internal conflict over one's sexuality - or because the pairing is just a coincidence.

Group Mythology. In order to operate as an integrated unit, groups with a common purpose also have mechanisms that they use to enforce conformity of thought within their numbers. Members employ various strategies to invalidate any competing ideas with which they might be challenged. Once again, group cohesion has its advantages; it often maximizes the group’s chances of success, but these mechanisms can also backfire severely and lead to failure.

Family therapists have studied groupthink phenomena within families, but similar ones are used by other groups as well. An individual's family often acts as if they all share a set of beliefs, and they all seem to live by them almost compulsively. While some of these beliefs are applied only to certain individuals, others apply to the whole group. The latter ideas are referred to as family myths. They justify and support a set of rules which dictate how each family member should behave and why, and what family roles each must fully and habitually play. This allows the family to function in a predictable way (family homeostasis).  

The myths function as a belief system which the family uses, often defensively, to explain or justify its behavior and beliefs. They are sometimes verbalized explicitly, but can also be expressed implicitly. Sometimes they take the form of oft-verbalized adages or slogans. One good example of this was seen in a family that strongly believed in fatalism—the idea that people are powerless to change their world so one should make the best of that which already exists. They all spouted three different proverbs on numerous occasions that expressed and reinforced within the group a warning about what happens to anyone who tries to take charge of their lives: "The grass is always greener on the other side of the hill;" "The devil you know is better than the devil you don't know;" and "You've made your bed so now you have to lie in it." 

Within-group Mechanisms for Enforcing Groupthink: Disqualification and Invalidation.
Individuals can, when necessary, use two related mechanisms to obfuscate their own real beliefs to themselves or others. This is done so that if later said beliefs are rejected, the persons can deny they had meant what they had in fact said. These tactics are called disqualification and invalidation. Disqualification is a strategy used to make one’s own position on an issue ambiguous. When someone does this, other members of the group cannot say for certain what it is that the person actually believes. When other people ask for clarification, they are basically told that they are misperceiving in some way the person they are asking. Doing this to them is an example of invalidation. 

Tuesday, December 3, 2019

Is Self-Determination Selfish?

“The more we plug in to what turns us on, the more of our light we can shine on those we love.” ~ Regena Thomashauer

Recently I gave a promotional talk at a local bookstore about my self-help book for adult children with problem parents. Its subject is how to get invalidating, demanding, and critical parents to stop that behavior, which in turn feeds into the adult child's own behavior. I discussed how getting their parents to stop allows people to then feel freer to follow their own muse, so to speak. The therapy-speak word for such self-determination is self-actualization

Self actualized people can focus on what they enjoy doing, choosing their own way in love, work and recreating, and having well thought out opinions about everything. They tend to be much more likely to realize their own potential, without sacrificing themselves completely in order to fulfill the desires of their families.

During the Q & A, someone from the audience asked me if self-actualizing in this way isn’t a selfish thing to do. Having heard a lot of objections to my views, and having written about how altruism can backfire and cause harm not only to the persons making certain types of sacrifices but also to the people they are trying to help (pathological altruism), I was still a bit taken aback by the question. Living life the way you want to might be considered selfish by some people?

Well, I suppose it is, but what’s wrong with that? The word selfish has a negative connotation. For every quality that human beings can possess, there is a word for that quality with a positive connotation and one with a negative connotation. Are you loyal or are you a bootlicker?  In this case: Are you selfish, or are you free-spirited?

Self actualizing hardly means that you won’t ever be willing to make some sacrifices to help or please other people, or compromise with others. Surely, like when someone gets married, they can’t just do whatever the hell they want to whenever they want to. They have to take into considerations the needs and desires of their spouse. The paradox is that, if you are self actualized, you do that because making your spouse happy is something that makes you happy. You aren’t doing it out of guilt or because you are intimidated, but purely out of love.

Having said that, making sacrifices for loved ones by trying to be something you are not is actually bad for relationships, not good. If a potential mate desperately needs something from you that does not under any circumstances feel at all right ever to you, that is a big red flag. It is a strong signal that you need to find another relationship; it should be a deal breaker. Otherwise, should you proceed and tie the knot, both of you will be utterly miserable in the long run.

Further complicating matters is that in most cases when your parents and the rest of the family seem to want you to be someone you are not, the messages they give you to do so are not at all clear-cut. Often the other family member needs you to do this in order to temporarily solve a conflict or ambivalent feeling towards some issue they have within themselves. This causes them to give out not a consistent or coherent message, but a double message. Damned if you do, damned if you don’t. Not only that, but your acting out in this situation will usually prevent constructive conversations which might actually solve a chronic problem. This is pathological altruism at its worst.

Tuesday, November 5, 2019

Why are Some Psychiatrists Such Wimps?

“Most psychiatrists are working in toxic practice environments that were designed by business administrators and politicians. As a result, psychiatrists are expected to see large numbers of patients for limited periods of time and spend additional hours performing tasks that are basically designed by business administration politicians and have no clinical value.” ~ George Dawson, MD

With the exception of those who are in “concierge” practices who do not take insurance and treat only those who can pay significant fees, very few psychiatrists—even in private practice—are doing any psychotherapy at all—other than being supportive with their patients. As mentioned in Dr. Dawson’s quote, some don’t do it because, simply put, they aren’t given the necessary time. They have to see several patients per hour, and are also too busy filling out completely useless symptom checklists on electronic medical records. 

Others are not interested in psychosocial issues and see everything in the DSM, the profession’s diagnostic manual, as a brain disease in need of medication – even “adjustment disorders,” which by their very definition have strictly psychological and social etiologies and do not require medication. Still others won’t do therapy because it doesn’t pay well. (Even psychologists are doing less and less long-term psychotherapy because insurance companies will not authorize it and keep ratcheting down fees, and they have been advocating for prescribing privileges. However, that is not the subject of this particular post).

Medical and psychiatric newspapers are filled with stories of physician “burnout” - being exhausted or depressed over their unpleasant work situation. Business and insurance companies work hard to convince these cases that the problem resides with their stress tolerance, rather than with their stressful working situation, and that they need to practice more mindfulness.

Meanwhile, hospital beds for the chronically mentally ill – those who do have actual brain diseases and are in desperate need of medication – have started to disappear. Along with that, the Community Mental Health Centers which once treated them with close follow up have been defunded by the states and the federal government. These two developments have resulted in many of these people living on the streets or languishing in jails, which have become de facto mental hospitals.

So who’s to blame for all this? Surely tax phobic politicians and greedy business interests share the lion’s share of the responsibility. Dr. Dawkins in his blog, from which the quote at the start of the post comes, seems to think that psychiatrists have no responsibility here, because they have all been forced to conform to the whims of businessmen with zero knowledge of medicine dictating how they should practice. But don't they really?

I think one of the main problems with the psychiatrists is that many of them are really a bunch of wimps who are too friggin’ chicken to band together and say “no” to their task masters. Of course, a lone doctor who tries to do that by himself or herself can be fired or made an example of. I recall my own experience at the VA when I had the nerve to protest in the patient’s chart that I had to prescribe a drug I knew would not work for a patient with both chronic pain and depression, before I could prescribe the more expensive medication which had been shown to be the most effective for that (while the rheumatologists could use the more expensive drug first line). I was offered an “anger management” seminar to treat me because I was angry that veterans were being screwed!

But can the business interests fire every one of their docs if they all refused to go along? Hell no!

There is a national shortage of psychiatrists. When you are in demand like that, they need you way more than you need them. In fact, as a member of the professional networking site LinkedIn, I have been asked to be part of their network by 22 different recruiters in just the last two months alone! And that was pretty much representative of the numbers of recruiters trying to snag me for a position every two months for the last several years. BTW, my profile clearly states that I am retired.

What a bunch of wimps these doctors are. You’d think it would take a lot of willpower and self esteem to get into and through medical school and residency training, and it does.  But doctors-in-training are also bullied, hazed, and forced to submit to the medical school hierarchy even when they know that their superiors are in the wrong. 

Until it was prohibited a few years ago, medical interns routinely worked 36 hours straight several times per month. (This was justified by the powers that be as being necessary because, they said, if there is an epidemic, doctors have to be able to work until they drop. The only problem with this rationalization was that the last major epidemic in the United States was the flu epidemic of 1918. By the time the next one rolls around, the doctors will be out of practice for 36 hour shifts, not to mention out of shape. No, this practice was hazing, pure and simple).

In other words, doctors are trained to act like sheep, and after they finish training many still act like sheep. Psychiatrists are no exception. How irritating. So my answer is yes, we psychiatrists are indeed part of the problem.

Monday, October 14, 2019

Different Schools of Thought in Psychotherapy

At last count, there were over 200 different "schools" of psychotherapy, each with its own ideas about why people act in self-defeating ways or in ways which bring them emotional or even physical pain, and how to help them to stop. Of course psychotherapy is, despite having been around for a hundred years, a young science, but our field is more difficult to study “empirically” than any other. 

The problems we have are enormous because we cannot read minds, and people can choose to some extent how they react to any therapy intervention. Patients withhold information about their situations from therapists all the time due to protecting their families from negative judgments, guilt, shame, or a concern the therapist might not be interested in it.

In psychotherapy outcome studies, seemingly minor variations in therapist techniques that are in fact vitally important (such as body language and tone of voice) aren’t even measured. There are no good active control treatments, and, when two therapies are compared,  the therapy method favored by the first author of the study comes out ahead 85% of the time due to the authors’ biases (allegiance effects). 

We cannot do double blinding because that would mean the therapists wouldn’t know what they were doing, which would not be a good test of the treatment. And of course once again there can be a major lack of complete candor by subjects. Much of the study results are based on patient self report, a notoriously unreliable method of data collection. And there is no way to distinguish an act patients may be playing for their family of origin (a false self or personafrom their real beliefs and feelings, or performance from ability.

The ecological fallacy – thinking all patients with a particular disorder react exactly like an average patient - is rampant in the literature. If 20 % of clients with a particular problem respond to one intervention and 40% respond to a second one, this does not mean that the second one is better for everyone than the first. The 20% who responded to the first one could actually get worse with the second one.

There is also a huge and highly problematic groupthink problem in the psychotherapy field, with purveyors of various schools claiming a monopoly on truth. Often the need for ideological purity, the admiration for an academic leader within a hierarchy, or the profit motive causes science to take a back seat in favor of a group's other interests. 

Fallacious arguments ensue. One of the most common is that entire complex groups of theoretical constructs that characterize a given school are rejected in total by another school, as if, if one theoretical part of a school is wrong, the whole thing must be wrong. Psychoanalysis may have been wrong about penis envy, for example, but dismissing intrapsychic conflict entirely as a construct because of that is - in a word - stupid.

Another is that a phenomena that two schools are looking at but explain differently are just being called different names and are given different explanations, which are then accepted by a given school as gospel without even a thought to investigating other possible explanations. I recently wrote in a post about how both the cognitive-behaviorists' "irrational thoughts" and the psychoanalyst's "defense mechanisms" probably serve the same purpose, but that neither school explains that purpose with reference to group dynamics - IMO the key factor.

There is still hope. IMO we have to look for recurring patterns in our therapy patients (not in research subjects, because contact is minimal) as well as within their social milieu. At times, we have to meet with clients along with their significant others in order to get a more well-rounded picture. We have to do so in long-term psychotherapy, because it takes quite a while for the whole story to unfold. 

We should do this in order to figure out commonalities and in order to figure out what questions to ask. In particular, we should look for evidence of motivated reasoning in what our clients report – logical fallacies, inconsistencies and contradictions (sometimes voiced months apart – the importance of extensive therapy notes cannot be overestimated), and defensive reactions. If handled well, this will help us unearth what clients may be trying to hide from us. 

Doing so also suggests questions we may have not thought to ask, or pay attention to environmental variables we were not even aware of that turn out to be major contributing factors to psychopathology that demand attention.

Tuesday, September 17, 2019

The Myth of the First Three Years

Obviously, people of any age can learn new information and change their behavioral responses to a wide variety of environmental contingencies. If that were not true, and people could not adapt to changing environments throughout their lives, it is highly unlikely that homo sapiens would have survived as a species. After all, we are relatively small, not particularly swift runners, have no natural armor or large talons with which to defend ourselves, and can die from extreme temperatures at either end of the thermometer. And yet, here we are.

The entire practice of psychotherapy is in reality predicated on the view that change is possible. If people become immutable at a certain age, then how would therapy ever help them change?

Ironically, however, somehow schools within the field of psychology often like to insist that most of our habits are completely fixed during childhood. According to the early psychoanalysts, for example, our personalities are completely developed by the time we are 5 years old. People with borderline personality disorder were thought to have “fixated” at the age of two! This meant that any psychological development after that completely stopped.

Neuroscience data is frequently cited by people who like to think they have neuroscience expertise but really do not – like many of today’s “biological” psychiatrists. In doing so, they often make assertions based on study results that have limited applicability to the psychological phenomena under discussion, or have no basis in findings from studies whatsoever. A book (recommended by parenting columnist John Rosemond) that came out way back in 1999, The Myth of the First Three Years by John T. Bruer, Ph.D, describes a particular heinous example of pseudo neuroscience that took hold with the participation of several politicians and celebrities. The misinformation is thoroughly dissected by Bruer.

The dumb idea goes something like this: the neurons in the brain develop hundreds or even thousands of synaptic connections per second until we reach the maximum number of such connections at age 3. The connections then start to be pruned. This means that the number of synaptic connections decreases over time. Therefore, kids under three need to be properly stimulated. They must be read to, learn their abc’s as early as possible, attend pre-schools, and listen to a lot of classical music. They need to become “scientifically correct.” If not, a window of opportunity will be closed forever.

This idea has led to a lot of parental guilt and anxiety, which my readers will immediately know that I think is far more damaging to kid’s psychological development than missing too much Mozart. Because of kin selection, we are probably more affected by the emotional state of our attachment figures than pretty much anything else that isn’t crazy severe like being under constant physical threat by one’s government. 

Parents who feel they may have damaged their child by, say, putting them in the wrong day care program (or heaven forbid, not putting them in any day care program at all) often become emotional wrecks who then overindulge their children, trying to prevent them from experiencing any or all emotional stress. When they seem to failing at that, as they must, they may then at times react with fury and even strike out physically with a child.

In reality, synaptic pruning probably leads to much higher brain efficiency in reacting to the environment in which the child is raised, but some people got the insane idea that the loss of neural connections after age three means something entirely different. They think that the period between ages 0-3 determines your IQ among other things, and if we want smarter and more resilient kids we must provide the proper stimulating environment or the development of our future abilities will be compromised severely. 

It is true that some aspects of the nonsensical idea may have  limited applicability to some of our psychological abilities - like learning a second language without having an accent. Almost impossible to do after the age of 12-14. But to think that somehow all of our abilities are like that is patent horse crap. Undoubtedly some of the neuroscience described in Bruer's book has become out of date due to increases in our scientific knowledge base in the last decade, but I think his basic premises remain intact.

What may get fixed in the first three years is that children become permanently much more responsive to their attachment figures than to anything else in the environment. The “serve and return” process described in an earlier post is probably related to this. Most neuronal tracks in brain are plastic in that they can form, or become stronger or weaker, over one’s entire lifetime. However, certain nerve tracks in the limbic system that are conditioned by one’s environment to respond with fear are highly resistant to major alterations. Certain faces – faces of kin – may trigger and reinforce a lot of automatic social responses to different people and situations.

The idea that children who are exposed to one environmental event or another develop immutable brain changes - other than those exceptions just listed - has even affected the highly important research in adverse childhood experiences like child abuse. Researchers do brain scans of abuse victims as adults and compare them to control subjects who had more loving childhoods, and differences in the size and activity of certain tracks remain. Hence, these researchers state, these brain changes are now irreversible.

Well they may be, but we still don’t really know. I kind of doubt it. There is some limited evidence that some of the changes can modulate with therapy, as described in a recent review article in the German journal Nervenarzt (November 2018) by  Schmahl, Niedtfeld & Herpertz. Their conclusion:

Although the overall database is still sparse, clinical improvement in psychotherapy appears to be associated with modulation of brain structure and function. Frontolimbic regulation circuits including the amygdala, insula, anterior cingulate cortex (ACC) and other prefrontal areas appear to be involved in these changes. An important finding is the eduction of initially increased amygdala activity after successful Dialectical Behavior Therapy (DBT).

Interestingly the last author, Herpertz, tended in the past to over-emphasize biogenetic factors over interpersonal and other environmental factors when I have spoken with her at meetings.

The folks that do the studies on untreated adults seem to think that, because they are no longer being actually beaten or molested, that the involved brain tracks are no longer being strengthened through environmental reinforcement. That also must mean that continued negative interactions with the attachment figures have come to a complete stop. Nonsense. These children continue to be around them throughout their lives, or in some cases do cut them off, but hear about them through other relatives. The “different” brain structures are thusly maintained. If that reinforcement were to be corrected, maybe those tracks would start to revert back to the size and activity levels seen in the control subjects. 

In order to know, scientists have to take into account whatever happened in childhood plus everything that happened afterwards.