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Thursday, September 17, 2020

What Ever Happened to Family Systems Psychotherapy?

 



Back beginning with the March/April 2001 issue of a magazine that was originally produced for the followers of the new family systems psychotherapy models, it changed its name from the Family Therapy Networker to the Psychotherapy Network. The magazine had started 20 years earlier in January, 1982. What happened?

 

The editor of the magazine then and now is a fellow by the name of Rich Simon. In the March/April issue of the magazine in 2012 he related the fascinating history of why this happened in an essay called Still Crazy After All These Years? A Look at 30 Years of the Networker.

 

Back in the 1980’s and 1990’s there was an explosion of new ideas about how to get psychotherapy patients to change both their behaviors and their negative moods that went well beyond the three basic paradigms or schools of therapy at the time: psychodynamic, cognitive-behavioral, and emotion-focused. Something like 300 different schools came to be, although most of them were just variations on the existing schools.  The Milton Erickson Foundation in Phoenix, AZ sponsored several “Evolution of Psychotherapy” Conferences in which the leaders of the various schools came to argue with each other in front of large audiences.

 

Family Systems therapy was the most noteworthy of the new models, because it was seemingly the first to recognize that since human beings are among the most social of all organisms, perhaps looking at herd behavior might tell us more about human beings than just looking at them in isolation.

 

Of course, even within systems therapy, there were quite a few widely varying ideas about how to proceed with psychotherapy clients. In the beginning, the Networker profiled the colorful characters who were coming up with them: Salvador Minuchen, Jay Haley, Murray Bowen, Mara Selvini-Palazzoli, Virginia Satir, Ivan Boszormenyi-Nagy, and Carl Whitaker.  

 

Of course, just like in all of the earlier schools, there was also plenty of nonsense within the movement. Some theorists imagined a sort of Zen perspective in which the thought that we had individual selves to call our own was an illusion. They became like extreme behaviorists, who instead of viewing humans as rats in a physical maze, viewed them as rats in a family homeostatic maze - with no ability to think for themselves. 


Others started explaining real brain diseases like schizophrenia on the basis of family double binds, which themselves were very common in the families of people without any schizophrenic members. Still others viewed the dynamics of any particular family as if they had just come into being as is, without reference to the cultural milieu in which they developed. Even Murray Bowen, who developed a three-generational model, only looked at who was enmeshed or at odds with whom, without specifying over what behaviors they were enmeshed or at odds about.

 

According to Simon, feminists started complaining that women seemed to be getting the brunt of the blame for, as well as the responsibility for changing, the family dynamics - especially when patients with histories of child abuse became brave enough to come forward. The latter issue also led to a reaction in which people were accused of having “false memories” (and which were being prompted by some therapists if the people were suggestible enough). Some elements of society were also upset with the so-called “abuse excuse” in which victims were seemingly encouraged to see themselves as permanently damaged victims who took no personal responsibility for themselves.

 

The confluence of converging forces mentioned in the masthead of this blog then started to develop with a fury. Longer-term treatments were no longer being covered by insurance, which only covered symptomatic treatment. Bogus “medical necessity” criteria were used to drastically cut down the number of sessions therapists could administer. Drugs were pushed even for diagnoses for which there was no good evidence that they worked at all. “Major Depression” became just ‘’depression.”

 

“Biological” psychiatrists who were not even aware of the latest discoveries in neuroscience pushed a disease model for everything. In fact, science has clearly showed beyond a reasonable doubt that the structure of the “plastic” human brain is in part determined by interpersonal interactions, and that most of what we do is learned and done automatically in response to environmental clues without any conscious deliberations.

 

Simon added that they did take a lot of flack after the magazine got renamed for “abandoning” systems therapy, but, “…as we saw it, we were just creating room for a bigger, more diverse “blended” family of therapeutic approaches.”


Tuesday, September 8, 2020

Parents who Feel Both Guilty and Angry About Their Parental Performance




I recently received an e-mail from an irate reader of my blog on Psychology Today. It was in reaction to a post I wrote about parents who were cut off by their adult children acting as if they had no idea why that happened, when in fact the majority of them (but certainly not all of them) have at least a pretty good idea. She told me I was an a**hole who was automatically calling all such parents “dicks” and “a**holes.” I of course actually made no statements like that in the piece.

Of course, if a history of child abuse is involved, which it may or may not be in such cases, parents have the responsibility for that and not their children, at least before the children grow up and have minds of their own. But this was not the subject of the post.

I wrote back to her:

Sorry if the piece sounded like I was calling the parents a**holes. I don't believe that. And of course not all families that have problems like the ones I describe [in the post] are in denial about what's going on. I view everyone in the whole family as all caught within a devilishly-difficult problem to solve that is created by a variety of external factors over at least three generations. 

I never recommend cutting off parents -  even when the parents actually were (unlike you) physically or sexually abusive - and take a lot of heat for advocating that they try to work things out for everyone's eventual benefit (not that it is at all an easy thing to do this).

I of course have no way of knowing anything about particular families like yours without ongoing in-person evaluation and therapy, so what I'm about to say may or may not apply to some degree to your situation. In some families in which parents, in the estimation of the adult children, seem to be frequently beating themselves up with guilt about their worth as parents, the kids worry that they need to fix that. And what they then do is start to piss the parents off on purpose to make them feel angry at them instead of guilty. Hatefulness as a gift of love, as it were..

That last bit referred to how, in the patient with borderline personality disorder’s spoiler role, the adult child is regulating their parents’ de-stabilizing internal conflict over having children (described in this post). When the parent starts to feel too guilty, their children make them angry. When the parents start to get to angry, they lay guilt trips on them.

As I said in my reply, I don’t know if that dynamic applies to the writer and her children or not. So what made me think that it might very well apply? Well, there were certain sentences in the writer’s original inquiry that seemed to indicate a lot of guilt as well as a lot of anger:

Implying guilt:

  • “I have admitted and apologized for the times I was a bad parent, naming specific incidents and listening to them to tell me other times they were hurt by me. I try as hard as I can to listen, be supportive, and not be overbearing.”
  •  “I don’t know that any parent who needs to be told they’re a dick would accept that from you. It made me feel defensive and hurt, all over again. Trust me, most of us a**hole parents don’t realize we’re being a**holes.”  
  • “I really do not know why my kids, especially my younger daughter, hold a grudge against me.  They have never said anything that I didn’t acknowledge, apologize for, and try to make right.”   

Implying anger/defensiveness:

 

·         Calling me an a**hole for allegedly implying she might be an awful person when I hadn’t actually said anything of the sort, and accusing me of “taking sides.”

·         “If they are mad because I turned out not to be perfect, but downright human and not always the best decision maker when it came to parenting, well, I at least know I always loved them immensely and would have, & still would, die for them.”

 

You be the judge.

 


Friday, August 14, 2020

High Index of Suspicion vs. Hyper-reactivity in Borderline Personality Disorder





One of the main themes of this blog is how researchers in psychiatry continually mix up learned or conditioned responses with disease states. These include misinterpreting fMRI findings and data derived from twin studies. I have also discussed something called Error Management Theory, which predicts that if you come from a toxic and crazy environment like someone with borderline personality disorder (BPD) does, and have to learn how to react to it, it is in your interest to have a high index of suspicion about the others around you. Somehow this has turned into emotional “hyper-reactivity” as some of sort of brain pathology or abnormality.

Now comes a study that seems to be strong evidence for my point of view. (Borrolla, B., Cavicchioli, C,., Fossati, A., and Maffei, C. “Emotional Reactivity Borderline Personality Disorder: Theoretical Considerations based on Meta-Analytic Review of Laboratory Studies.” Journal of Personality Disorders 34[1], 64-87, 2020). 

The authors did a meta-analysis (combining the data from several studies) which addressed the question.

Variables measured in these studies included heart rate, respiratory heart sinus arrhythmia, skin conductance, cortisol (stress hormone) levels, startle response, blood pressure, and patient self report.

Their conclusion: the hyper-reactivity hypothesis was in general not supported. The apparent increase in reactivity in BPD could instead be attributable to their tendency to evaluate emotional  stimuli more negatively than controls. Exactly what error management theory would predict!

The study authors go on to say that amygada functioning (basically fight/flight/freeze reactions) concerns “several processes that go beyond emotional arousal (salience and novelty detection, reward learning, memory, attention modulation, decision making…” (p. 79).

Exactly. And Amen.

Tuesday, July 21, 2020

Measurement of Outcomes in Psychotherapy of Personality Disorders Ignores Social Context



On June 22, 2020 I received an e-mail from the International Society for the Study of Personality Disorders (ISSPD), an organization to which I belong, announcing that a group whose purpose is to define standard outcomes in research on various medical conditions came up with such a list for outcomes in psychotherapy for personality disorders.

It read:


BOSTON, Massachusetts, June 2, 2020: The International Consortium for Health Outcomes Measurement (ICHOM) announced the release of their Personality Disorders Standard Set today. 

Leading mental health researchers, practitioners, and service user representatives from across Europe, North America, Asia, and Australia have joined forces to establish and launch the first international standard for measuring treatment outcomes for adults and adolescents aged 12 and above with personality disorders. This marks an important step towards promoting data quality and availability, and strengthening mental health care for this group.




As my readers are probably aware of by now, I have been critical of outcome studies in the field for a number of reasons, not the least of which is the researchers’ obsession with what is going on inside people’s heads while ignoring what it is they are actually reacting to. The focus has been entirely on a decrease in symptoms, not on the specific behaviors of self and others and the resultant difficulties in patients’ relationships which then lead to the symptoms. The primary attribution error personified. Did the relationships of subjects improve or not? We never knew.

Not that symptom relief isn’t important. It’s difficult to function at all, let alone focus on difficult issues, in the midst of panic or rage attacks. Self injurious behavior is also a huge problem.  I put most of my psychotherapy patients who had borderline personality disorder on meds so these symptoms were controlled in many of them – and, I might add, much more quickly and effectively than through psychotherapy or mindfulness training. In fact, the type of therapy I used (Unified Therapy) can not be done at all without some control of such symptoms, because the therapy focuses on the anxiety-producing issues with which I think patients must deal. 

However, symptoms are not at the heart of the disorder. Personality disorders are clearly and obviously (at least to me) disorders of interpersonal relationships that include a wide variety of family members and romantic partners. These relationships involve issues that are often somewhat unique to each person (the ecological fallacy is widespread in this research). Those are what need to change in order for  symptomatic improvement to last very long. And if any of them have changed after therapy, none of the changes have been measured in typical psychotherapy outcome research.

So I was anxious to see if the new data sets announced in ISSPD’s e-mail might include some of the actual problems which create personality disorder symptoms. Of course, they did not. The circle that is at the top of this post shows the areas under consideration and what tests are supposed to be used to measure them. Here’s a list of the measurements. The numbers refer to the ones in the circle  next to the name of each subsection:

The standard set
The ICHOM Standard Set for Personality Disorders is the result of hard work by a group of leading psychiatrists, psychologists, mental health experts, measurement experts, and lived experience experts. It represents the outcomes that matter most to adults and adolescents with personality disorders. We urge all providers around the world to start measuring these outcomes to better understand how to improve the lives of their service users.
1.        Defined by Emotional Distress/Emotional Pain
2.       Defined by Affective Lability/Emotional Dysregulation
3.       Defined by Self-harm/Self-injury
4.      Defined by Overt Aggression
5.       Defined by Global/Daily Functioning/Disability
6.       Tracked via the Level of Personality Functioning Scale - Brief Form 2.0
7.       Tracked via the Recovering Quality of Life - 10-Item Version
8.       Tracked via the Difficulties in Emotion Regulation Scale - 16-Item Version
9.      Tracked via the Columbia Suicide Severity Rating Scale - Screener/Recent - Self-Report
10.   Tracked via the Modified Overt Aggression Scale
11.     Tracked via the WHO Disability Assessment Schedule 2.0 - 12-Item Version
12.    Tracked via the KIDSCREEN-10 Index in Adolescent Specialist Services
13.    Tracked via the PROMIS Short Form v2.0 - Social Isolation 4a

Almost all of these outcomes are to be measured in terms of how often subjects experienced difficulties during a wide variety of activities or how often they felt bad, but nothing about whether any changes had taken place in the subjects’ lives which might account for the reasons behind any such pre-existing problems. Subjects are asked if they are having difficulties which such things as getting started with everyday activities or doing things they found rewarding. They are asked if they can enjoy themselves.

They are asked if they feel lonely or in control of their lives, but not about why. They are also asked if they feel that the people around them are causing distress, but absolutely nothing was asked about what the interpersonal problems creating the distress actually were exactly or whether or not they had been effectively addressed in therapy.

In the circle are three general life areas which I thought might expand the outcome horizon in the desired direction: Interpersonal and social functioning, sense of belonging, and health related quality of life. So I looked at the outcome measures ICHOM was recommending. Once again, the same issues reared their ugly heads.

Interpersonal and social functioning was tracked via the WHO Disability Assessment Schedule 2.0 - 12-Item Version. Sample questions: In the past 30 days, how much difficulty did you have in: learning a new task, joining in community activities, dealing with people you do not know, maintaining a friendship, and in your day to day work.  Once again, how much but nothing about what the specific difficulty involved were and why, and nothing about family or love relationships. 

Gee, and here I was naive enough to think that interpersonal functioning requires the participation of at least two people!

Sense of belonging was tracked with the  PROMIS Short Form v2.0 - Social Isolation 4aSample questions: How often have you experienced feeling left out or isolated from others? Again, nothing about isolated from whom or why or what is creating any continuing such problems.


Health related quality of life was tracked with Recovering Quality of Life - 10-Item VersionSample questions: how often did you have trouble with such things as trusting others, enjoying what you are doing, feeling confident in oneself. Nothing about which relationships or even which areas of life these feelings occurred within, or what was happening which might have led to these feelings.


Truly, the science here continues to leave much to be desired.

Tuesday, June 23, 2020

Parenting Critic John Rosemond





In my post of 10/23/18, I reviewed Lukianoff and Haidt’s book, The Coddling of the American Mind. This book looks not only at political correctness as an impediment for finding truth in the universe, but what the authors see as a related issue: why the rates of depression, anxiety, drug abuse and suicide have been rapidly increasing in college-aged kids and others over the last few years.


They document the rise on campuses of efforts to “protect” students from “microaggressions” and the need for “safe spaces” and other such nonsense, assuming that exposure to other opinions and the occasional ethnocentric or racist comment, even offhandedly, is some sort of psychological trauma.

This seems to be the culmination of a major change in typical parenting styles that began in the 1970’s that has been brilliantly documented by psychologist and columnist John Rosemond. He discusses how parents now seem to treat their children as equals whose opinions on and feelings about everything are just as valid as those of adults, and are somehow not reactions to parents refusing to set appropriate limits with them. 

He believes, as I do, that the relationship between the parents should be the most important one in the house, not the relationship between either parent and a child (although of course the latter relationships sometimes have to take precedence). This has the effect of making children act out and actually feel worse about themselves, in addition to not taking other people’s rights and feelings into account as often as they should.

Basically, he is accusing such parents of being chronic enablers interfering with their child’s development of independence and responsibility. He takes a lot of heat for saying this, just as I do (to a much smaller degree since I have a much smaller audience). He is accused of “parent bashing.” When asked about this, he says he is indeed a parent basher and is proud of it.

He blames a lot of these parenting problems on advice from the mental health community as well as their invention of psychiatric pseudo-diseases. Even picky eating has been turned into a mental disorder  - Avoidant/Restrictive Food Intake Disorder (ARFID).

Rosemond is one of my heroes. He was kind enough to give me a positive blurb for my book on family dysfunction and mental disorders. He is the author of a quote I frequently steal from him, "Taking responsibility for something and self-blame are horses of two entirely different colors. The former is empowering; the latter is paralyzing."

I totally agree with the vast majority of his opinions.


Of course, there are some areas on which we don’t see eye to eye. He does not write about how cultural developments have led to a lot of the parenting changes of which he writes - e.g., the high prevalence of guilty yet angry parents due to the culture wars. IMO, the problematic changes are not just due to bad advice from the Dr. Spocks of the world. 

He over-generalizes about all psychiatric diagnoses not actually being diseases because they are not accompanied by clear-cut, easily-seen brain pathology. Actually, this is due to our limited knowledge of very complex brain circuitry. And he seems to think that screen time per se is more detrimental to young children than I might think it is, as I focus more on how any damage from too much screen time is more a reflection of what happens when parents do not set limits than it is of any direct effect. 

But no matter. The world needs more people like Dr. Rosemond.








Tuesday, June 2, 2020

Bringing up a Family Issue, and Parental Defensiveness Ensues




On Psychology Today, “Riles” commented on my blog post: "The Family Dynamics of Patients With Borderline Personality:"

Parents huh? This article is such bullcrap.  Its obvious this therapist does not work with BPD individuals...I am a parent to a BPD son, we have never mistreated or abused our son.  My son, as most BPD feel as though any disagreement even over trash day is emotionally or verbally abusive to them...A 5 minute question session just to ask about their day in their mind eventually gets spewed as a 2 hour session of us yelling at him.  Its such crap that you put this out there blaming parents who are doing everything in their power to understand this disorder and help their children.

This sort of reaction is representative of the fact that bringing up family issues involved in creating BPD is dangerous for their adult children - as well as a minefield for people like myself writing about the situation. Yes, it is true that many parents of BPD offspring are not overtly abusive, as I have often mentioned.

However, let’s look closer at this comment. Let’s assume for the moment that it is an accurate description of what goes on in this family (of course, I have no way of knowing whether it is or is not). I would wonder how old the son was when these two-hour yelling sessions began. Clearly, their son is provoking them, but that is part of the dynamics in families that generate BPD. Spoilers make parents angry when they are too guilty, but then have to make them feel guilty if they start to get too angry.

I would advise these parents to ask themselves, if they can calm down long enough to look at the interactional patterns with their son somewhat dispassionately and honestly, why they continue to engage with their son for two whole hours when he starts to act like this. Chances are, this signals the son to continue doing whatever it is that he had been doing. If the parents say they don’t know how to put a stop to their son’s difficult reactions and/or disengage from him, I would suggest that they watch a few episodes of Supernanny or read a book by parenting advisor John Rosemond. I would also have to warn them that if they follow the advice, their son’s behavior will get worse at first - but then get much better.


Can “How was your day” be a loaded question in these families? Damn right it can. If the parents are usually over-involved (the Buttinsky bunch) or under-involved (the Alfred E. Neuman what-me-worry bunch), or even worse, if the parents vacillate between these two extremes, their asking about their son’s day would for him be an incredibly infuriating entrance to this pattern of interactions.

Tuesday, May 12, 2020

Psychotherapy with BPD: Another Conundrum





For therapists such as myself who also write about borderline personality disorder (BPD) for the general public, there are several ironies that make it a damned-if-you-do, damned-if-you-don’t proposition. In my post of 2/27 of this year, I discussed the issue of how describing what the parents are doing with their children can make those parents feel even more guilty than they already were, when guilt is what has been driving their problematic behavior in the first place. Therefore, they can get even worse rather than taking any new knowledge they may have gained as a way to reduce their problem behavior.

A similar issue takes place when adult children who have BPD read my discussions of family dynamics. For the role of spoiler that they are playing, part of what drives it is often their parents’ insatiable and unceasing efforts to “fix” what’s wrong with them. Because to all outward appearances their parents seem to want or need to continue to do so, their adult children must remain “broken.” That is, in need of fixing. The people with BPD also think this about their narcissistic romantic partners, who are also constantly trying to fix them - while seeming to feel that they are God’s gift to them. The more the partners try to do the fixing, the more they reinforce their mate’s spoiling behavior.

So guess what happens when an individual with BPD comes to see a therapist? The therapist’s whole purpose for existing is to “fix” what’s wrong with their patients! How can therapists not end up inadvertently enabling their patient’s spoiler role? It’s sort of like coming to see someone whose goal is to “make you independent.” How can someone really be independent if another person is making them do something?

In therapy, the way around this is for the therapist to validate the ample evidence their patients offer (even while sometimes pretending that this is far from the case) that they are smart and capable, and that “their” problem is not a personal defect, but trying to figure out an enigma. They are trying to come up with a way to solve an almost-impossible-to-solve problem: the conflicted, ambivalent dynamics of their family members.

Doing something equivalent to this therapy countermove when writing for the public is a rather devilishly complicated proposition. Even spelling out what I am saying here with disclaimers doesn’t always work because it’s easy for someone coming from a borderline-ogenic family to see that as a ruse to lull them into a false sense of security. 

I had one reader write to me to tell me that something I wrote, rather than being empowering, made her feel so helpless she made a suicide attempt. She didn’t say that what I wrote was wrong, it should be noted, and I would wonder if she already had a history of making suicide attempts. But still, I understand her request that I be more careful about what I write.

Another reason I might make persons with BPD feel helpless is that, if family members were to read my stuff and figure out what they are up to, then the people with BPD might no longer be able to successfully pull off the spoiler role. They would become less powerful because I gave away their "secrets."

Nonetheless, facing the truth is the only thing that can set free everyone involved in family dysfunction. Dysfunctional roles only stabilize families (homeostatsis) over the short run. In the long run, they prevent resolution of ongoing issues.

So there is hope, especially if there are more therapists who understand family dynamics. I continue to hope for potential patients to create a high demand for therapists to start helping them identify interpersonal triggers and find ways to avoid the typical negative consequences of change - rather than just focusing on what is going on inside their patient’s head.

Monday, April 27, 2020

The Book is Finally Out



Hot off the presses, my new edited book is now out.



Friday, April 24, 2020

Drug Abuse “Intervention:” Why it Works






In Jonah’s Berger’s excellent new book, The Catalyst: How to Change Anyone’s Mindhe discusses effective ways to get people to look at things in new ways. Even die hard ideologues can sometimes be reached using many of his methods. He also talks about why persuasive arguments and presenting new information in an effort by one person to get another person to reconsider entrenched positions usually does not work

In the chapter called “corroborating evidence,” he uses a successful “intervention” with a drug abuser to illustrate how, in influencing others, having multiple people give information is often much more powerful than just one person’s speaking , especially when the multiple sources are all operating at or near the same time. 

In the Intervention technique in substance abuse treatment, the actual intervention is having an outside therapist come in and coach the family members to write out a speech about how much they care about the user and how his or her behavior is hurting everyone. They are instructed to avoid telling him what to do. Nonetheless, the therapist has a rehab facility lined up in hopes that the object of the intervention will agree to do something about his “problem.”

They each say how sad they are because of the problem and how much they miss him and want the drug abuser “back.” They also give the addict the message, “If you want to be an addict, we can’t stop you. But if you want to get high, you aren’t going to do it here.” 

With families, Berger points out, several members have often -  over time and individually – “asked, begged, yelled, screamed, and threatened. All to no avail.” But then he goes on to say things that consist of the usual wisdom about these sorts of things, such as “They (addicts) don’t believe they have a problem.” They are “in denial.” They may not remember wrapping a car around a lamp post” because they “blacked out.” If an addict doesn’t think he has a reason to quit, “is one person really going to change their mind?”


That sounds reasonable, but is it really? Doesn’t the addict find out what happened to the car after he comes to? Isn’t losing a good job and resorting to crime to finance an addiction considered by the drug abuser to be problems? As I often say, he would have to have the IQ of a kumquat – or maybe a rutabaga, I’m not really sure – to not “know” he had a problem. So what’s really going on here?


Berger attributes the relatively high success rates of organized family “interventions” to the number of people giving a similar message. He's partly correct. But he also seems subliminally aware that there is something else going on here. He states, “In order to get addicts to change, their entire ecosystem has to be altered. Without realizing it, friends and family members may be unintentionally enabling the problems. So for change to stick, the whole system has to change…”


Was the particular family the author described enabling the abuser, “Phil”? Why as a matter of fact, quite so. In the author’s description, the family didn’t seem to think of him as an addict for extended periods, especially at first, because he had a job and didn’t steal to support his habit. He did start to steal a bit later. They sent him to rehab 19 different times even though each of them was unsuccessful. They repeatedly let him move back home. They resorted to having him sign a contract promising to turn over a new leaf, but all that did was to “train him to be a better liar.”


Hearing this, it might seem fairly clear why Phil may have thought his family was actually invested in him continuing to be an addict, because they made it so damn easy! Unlike most of us, they know that family members are not that stupid even if they seem to be “in denial.” Of course, I have to put the usual caution here: since I haven’t personally evaluated this family I can’t say what follows with certainty, although IMO what I am about to describe is extremely likely.


Another hint that the above formulation may be on the mark is a statement by the book author that "family was everything to Phil." The author thinks that Phil realizing he was tearing the others to shreds was the motive for quitting. But again, how could Phil possibly think that this hadn't been the case all along? Because he thought the family needed him to be an addict!

In dysfunctional families with shared conflicts over certain behavior, say for example puritanical attitudes towards work and intoxication, several members are usually involved in either enabling or refusing to notice the problems of the addict. The addict is actually taking the cue to deny that he has a problem from the family. When one member occasionally seems to object about addict-like behavior, another family member may give the addict the opposite message. In such a situation, this can become a game without end even more easily than when just two people are stuck in this game. So no wonder the addict ignores the asking, begging, yelling, screaming, and threatening from any one family member.


However, when the whole family comes together to give the same message – that they all will no longer deny that the addiction has become a problem — and all clearly state that all of their enabling behavior in toto is going to cease, their wanting him to stop becomes far more believable. So it isn’t just multiple sources of info as Berger assumes, but the fact that they are all indirectly acknowledging their own contributions to the addict’s continuing addiction.


Of course, the addict may still be skeptical. If Phil leaves yet another rehab program without success, and his parents still let him return home, nothing will stick. In this case, that fortunately did not happen.



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 https://developingchild.harvard.edu/science/key-concepts/serve-and-return/). 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.