Pages

Tuesday, April 26, 2016

Successfully Confronting One's Family of Origin Members: What Comes Next?




A commenter on one of my blogposts posed what I thought were some very good questions. The post itself was about how some other therapists think I'm a horrible therapist because I send my patients who come from highly dysfunctional or abusive families back into the hornet's nest to confront and hopefully change ongoing repetitive dysfunctional interactions with family of origin members.

The anonymous commenter asked: Even if a patient is able to confront or dialogue with their parent to stem the abusive behavior, wouldn't that be just the beginning of the work of patient? Just because Mom and Dad have stopped being the insufferable fools that they are, a) they don't necessarily understand the family dynamics at work and b) their corrected behavior is not going to help the patient with his habitual emotional responses that have hampered his life. Once Mom and Dad have been more or less straightened out, what is the patient's next move?

I realized that, although I covered this in detail in my books for therapists, I had not really addressed the answers to these questions here in the blog. So here goes:

First of all, the dialog with the parents usually does include an empathic discussion of the family dynamics and the reasons for the parents' problematic behavior (metacommunication). The goal is to do this without condoning any of their past or current damaging behavior. That problematic behavior is the most powerful trigger and reinforcer of the patient's dysfunctional role within the family. (Many of these roles have been described in detail in previous posts, and are models for the various personality disorders).

How individuals play the dysfunctional roles in everyday life is based on a model in their heads of how to respond to various social situations with significant others. These models are called role relationship schemas. These schemas and the resultant behavior are performed automatically and subconsciously in response to various pre-determined social cues, and are therefore performed thoughtlessly in most situations.

When the parents stop feeding into and/or triggering someone's schemas, this seems to start to free the person up to experiment with alternate ways of relating to others. While going through this process, however, the individual may often also experience something called post-individuation depression or groundlessness in which they come to the realization do not seem know who they are any more. They have yet to become acquainted with the true self that they had been, before this, invariably suppressing throughout much of their lives. Paradoxically, their role behavior or false self feels real, while their true self feels false!

As a therapist, I explain this feeling to them and reassure them this horrible feeling will soon pass.

Many patients will then spontaneously start to experiment with new ways of relating to others. If not, typical cognitive-behavioral psychotherapy interventions from the therapist - which would have before this point been quickly overpowered by the reactions of family members - suddenly become very effective in moving patients forward.

Finally, the patient is instructed on how to handle the issue of family relapses. It is almost inevitable that they and the parents will at some future point fall back into their old dysfunctional habits. As we all know, long-time habits are indeed quite hard to break. However, once the earlier metacommunication had taken place, it is fairly straightforward to bring the relapse up with the parents and refer back to what had been discussed and decided upon earlier. The patient is instructed to wait until everyone cools down before attempting this maneuver.

Before I terminate therapy with a patient, I praise the patient for taking what we had discussed in therapy and employing that which we had decided to do so effectively. I believe it is important that patients take a realistic view about giving credit where credit is due, so they can have confidence that it was they who had actually accomplished the goals of therapy. This reassures them that they can therefore carry on without the therapist's help - and without the therapist having to pretend that the therapist had nothing to do with it at all, as some family systems therapists recommend.

Tuesday, April 12, 2016

Direct to Consumer Drug Advertising: There's a Sucker Born Every Minute




Have you seen them? TV and print ads advocating the use of a new drug called Rexulti as something that can be used to augment an antidepressant when the antidepressant alone does not completely relieve all of your symptoms. These ads are only slightly different than ads you may have seen in the past for Abilify, which was also touted for the exact same indication.

As it turns out, both of these drugs are manufactured and distributed by the same companies: Otsuka Pharmacuetical Company and its marketing partner Bristol-Myers Squibb. And guess what? Abilify recently went generic (which means its original manufacturer has lost its patent protection and therefore its monopoly on the drug) under its chemical name, aripiprazole. 

Rexulti's chemical name seems oddly similar: brexpiprazole. Coincidence?

Well here are pictures of the chemical structures of the two compounds.



Remarkably similar, no? In fact, these drugs have effects on people that are nearly identical, have only slightly different side effects, and they both have the exact same indications. And of course they are not antidepressants at all as many of you have probably been led to believe, but antipsychotics: meant to treat delusions and hallucinations in schizophrenia, bipolar disorder (the real kind), and major depression with psychotic features.

(BTW, we've always known that any antipsychotic medication can augment an antidepressant in some patients. However, they have potentially very toxic side effects, and there are other, safer drugs which can also augment an antidepressant, such as lithium and a thyroid hormone named T3. I think benzodiazepine drugs such as clonazepam do as well, but drug companies are not about to do studies confirming that, because benzo's are so cheap and free of side effects).

There is one very big difference between Rexulti and Aripriprazole: the price. Generic Aripiprazole will be much, much cheaper. Why on earth would anyone ask for an expensive drug when a cheaper, nearly identical drug with the same effectiveness and nearly the same side effects is available?

Well of course they would not. Which is where the direct to consumer ads come in. The company wants to keep up its profits, so it pushes their new drug without any reference to their old one. And people are suckered into demanding it from their doctors. As someone once said, no one ever went broke underestimating the intelligence of the American people.

Now I can't prove that the company developed Rexulti in anticipation of losing its patient protection on Abilify, but the timing is a bit suspicious, wouldn't you say?

Drug companies have lots of tricks to extend their patent protections aside from just coming up with new conditions for which a drug is indicated, coming up with an extended release version of the same drug, or newly combining the drug with a second drug. 

Some drugs are converted to other drugs in the body which are in fact the compounds that have the desired effects (active metabolites). So after the parent drug goes off patent, they release the active metabolite as a "new" drug. Think Effexor vs. Prestique.

Some drug compounds come in two different versions which have the same chemical formula but different geometry - the two molecules (enantiomers) are mirror images of one another. One of the two versions may be effective for a given symptom while the other may have little effect. So drug companies first issue a mix of both versions (racemic mixtures), and when that drug goes off patent, they release a drug which is  the pure, active enantomier. Voila, new more expensive drug, new patent, and the clock keeping track of how long the company retains exclusive ownership of the drug starts to tick anew. Think: Celexa vs. Lexapro, and Prilosec vs. Nexium.

So if you pay attention to those ads, you will be being taken as sucker.

Tuesday, March 29, 2016

Adult Children Who Cut Off Their Parents: an Interesting Variation on This Theme.




My posts on this blog (May, 27,2014) and on my Psychology Today blog (November 17, 2014), Are Parents Who are Cut Off by Their Adult Children Really That Clueless, generated more comments than almost any of my other post (37 and 163 respectively). Additionally, the post itself on this blog has had more hits than any of the others.

In the posts, I reproduced letters to newspaper advice columnists from parents who had been cut off by their adult children, and who claimed to have no idea why their adult children felt the need to do this. I also printed one letter from the adult child of one of those letter writers telling the other side of the story. Without addressing the issue of who's "fault" it was that the cutoff took place, or who was "wrong" and who was "right," I opined that the apparent cluelessness of the parents was in most instances feigned. They usually knew to a greater or lesser extent exactly why what had happened had taken place.

Well the comments from readers came fast and furiously from family members on both sides of this divide, and they were very predictable. Adult children who had cut off a parent generally wrote about all the bad things their parent had done to them and how the parent would never admit to any of it. Parents came back with a vengeance saying, in so many words, "I didn't do anything wrong," and they accused me of parent bashing.

Here's a typical exchange:

Anonymous: Yes, you are correct. Virtually all of the time, when people cut off parents, or anyone else in their immediate family, you can bet there's a damn good reason. The parents will act like the poor victims. Don't believe them. There's actually a forum on the Internet where they can all get together. At first they maintain their innocent victim stance, but you will soon see their vicious hatred expressed toward their children.

Emelu: Not so. I have done nothing wrong. I've been in counseling. Been open to understand if I did wrong. Been totally honest with myself. And there is nothing I've done wrong.

I always find it interesting that whenever I write posts - particularly on the family dynamics of borderline personality disorder - adult children with the disorder who make comments often seem to accuse me of blaming them, while the parents of such children often accuse me of exactly the opposite: blaming the parents.

In most of these cases, I think the reason for these opposite reactions has to do with selective reading of the posts. This, in turn, is triggered by guilt and defensiveness. Or, occasionally, some of these folks just hate it when I give away their secrets.

In general, both of the positions "It's all my fault" and "I had nothing whatsoever to do with this" are, equally, both irrational and cowardly for any of the involved parties. 

In cutoffs, however, can it sometimes be that the parents really are completely clueless about why their children are avoiding them? That they are absolutely at a loss to understand what has happened? Some commenters said their cut-off children even accused them of things that they know they did not in fact do. Is that always denial?

As everyone was taught in school about true-false tests, beware of any question containing the words "always" or "never." I do think that, in a very limited proportion of these cases, the letter-writing parents are indeed genuinely flabbergasted at their adult children's negative responses to them and the phony accusations. In these cases, IMO the adult children are hiding their real reasons for the cutoff.

So why would a child cut off a parent who was not guilty of any significant abuse, neglect, or invalidation?

One common reason occurs in situations in which the parents feel tremendously overburdened and overwhelmed by the responsibilities of child care, or feel that the child's needs are preventing them from doing other things that they really badly want to do. They feel guilty when they admit this, even to themselves, and they always take care of their children when they are supposed to, and do so appropriately for the most part. They do not usually take their internal frustrations over being exhausted directly out on the children to a major extent, and genuinely love them.

They think that somehow their children are not aware of how tired and frustrated they are, but they are kidding themselves. The attachment theorist John Bowlby theorized that children observe their parents very carefully, without attracting too much attention when they do, and become experts on what their parents are all about and what motivates them by the time the children are just two years old.

In videotapes of family therapy sessions with small children in the room that I have seen, as the therapist speaks with the parents, one may observe the child playing with a toy in the corner. The child seems to be oblivious to the adult conversation. But then, when something concerning them comes up in the conversation, the child suddenly makes a comment about it. Without even looking up. Clearly, they are listening the whole time.

Parents in the situation under discussion in this post do in fact give a lot of clues as to how burdened they feel. They might for instance constantly and compulsively complain to their friends and anyone else who might listen, saying something along the lines of, "I'm always there for my kids! They're my #1 priority. I respond to everything they need, even though I have to work full time. I so wish my boss would understand this better. There's just never enough time. And I'm sooooo tired. I used to have hobbies I really enjoyed, but I've had to put them aside. I sure do miss those days!"

Even after their children reach adulthood, parents like this may have a very hard time trying to not cater to their adult child's every need - or even his or her every whim. While still complaining about it to everyone else.

In such cases, children may get the impression that the parent really wants to be free of them, but just cannot admit it. In response, they sacrifice their own desires for a good relationship and make themselves scarce. They cannot tell their parent the real reason for their doing that, because they know that this will make the parent even more miserable than he or she already seems to be. 

A truthful statement would make the parent feel even guiltier for wanting to be free of any family burdens. The parent would probably deny these feelings anyway, because the parent is under the mistaken impression that admitting this would drive their children even further away.

In order to avoid causing their parent to feel this way, the adult child may in difficult cases volunteer to be the villain in the piece. They may purposely make it look like they are cutting off the parents because they are selfish or narcissistic. If that does not work, they can escalate. They up the ante by making what they know are false accusations about parental misdeeds. That way, the parent can easily maintain the belief that he or she had nothing to do with the cut off. 

As an alternate strategy, or in addition, they may influence their spouse to make it look like the spouse has taken control over them and is domineering and purposely creating trouble with the parent and enforcing the cut off. For more on this, see the post, Your Spouse's Secret Mission.

Anything to help parents avoid looking at their own conflicts!

This is a sad state of affairs because, ironically, if the parents could admit to their ambivalence and negative feelings, any problematic resultant family conflicts can in most of the cases be fairly easily resolved through metacommunication and negotiation. The children's efforts to "help" the parents to deal with their guilt backfires and prevents a solution.

I know that many readers react to these kinds of formulations by thinking I am giving people too much credit, and that most of them do not operate with this level of sophistication. When it comes to fitting in with one's kin, church, or ethnic group, I strongly believe that they not only can, but they do. 

Tuesday, March 15, 2016

Groupthink: A Paradoxical Type




A recurrent theme in this blog is that one cannot understand repetitive self-destructing, self-defeating, or self-subverting behavior without reference to group dynamics. Because of the forces of kin selection, we are all biologically predisposed to sacrifice our own needs/ideas/happiness in order to fit into the various kin and ethnic groups to which we belong - although we can all override this tendency and face the consequences if we so desire. 

Part of the way we fit ourselves into any group is to pretend to subscribe to the validity of the rules and ideas shared by the other members of our group: what is today called groupthink.

I recently came across an idea about a peculiar and almost paradoxical phenomenon which is one interesting manifestation of groupthink. It is known as the Abilene Paradox, first described by Jerry P. Harvey in 1974. It is similar to my idea about what is going on with members of couples embroiled in repetitive dysfunctional relationships. Members of such couples almost always assume that it's the partner, not they, who want and need their relationship to continue in its current miserable form (cross motive reading).

As described by Harvey, the Abilene Paradox is based on a personal experience in which his family all agreed to travel over 50 miles in extreme heat and in a non-air conditioned car in order to eat at a restaurant in Abilene, Texas. In reality, not a single member of the family actually wanted to take this trip when someone suggested it. However, every single one of them mistakenly believed that all the other family members were in favor of going. 

And so they all went, and they all were miserable for the entire trip.

This is sort of the inverse of the situation in which an individual who has reservations about a group decision goes along with a group on some idea or project when the other members all, in fact, do think it's a good idea. The end result in each case is of course exactly the same: everyone goes along with the idea. In many such cases, the altruistic intention backfires and ends up harming everyone.

Going along to get along in a business atmosphere, as mentioned in a previous post, can eventually lead to the demise of an entire business. Harvey also discussed the Watergate scandal as another example of a situation in which everyone went along with an idea that they mostly all knew was a terrible one, because that was what they thought everyone else wanted them to do.

Sometimes, what fools these mortals be.

Tuesday, March 1, 2016

More Baloney about Implanting False Memories


TV show available at http://www.pbs.org/wgbh/nova/body/memory-hackers.html

In an otherwise excellent episode of Nova on PBS about recent research into memory - available for viewing in its entirety at the website above - the show takes what is for me a disturbing turn around the 38 minute mark. It starts to discuss the issue of whether false memories can be implanted in people. An academic psychologist named Julia Shaw discussed her experiments which she believes "proved" that you can induce in someone a memory of a crime in the distant past that they did not actually commit.

Dr. Julia Shaw


According to an article in the New Yorker, Shaw modeled her work after that of child abuse apologist and memory pseudo-expert Elizabeth Lofton. Shaw claimed that she was able to induce this kind of false memory in 70% of her subjects. Of course, even if this were true, it means that she was unable to supposedly accomplish this feat in almost one third of her subjects, which leaves us with the question of what distinguishes that portion of the sample from the others.

But leaving that aside, let's look at the experiment she did, as shown with a film of one probably illustrative subject during the experiment. The experimenter brought up a supposed incident that occurred when the subject was 12 years old. Dr. Shaw told the subject that the subject's parents had told her about the false incident. She said, "What happened was you initiated a fight that was so severe that the police called your parents. They said it happened in the fall when you were with Ryan when it happened." She mentioned two facts that were in fact true - a move the family had made around that time, and the name of someone she knew.

The subject's first response was not surprising, and it was quite definitive - if not emphatic. As I relate the dialog in the experiment, I want readers to notice that the subject moves from a quick and clear-cut response at first, denying this happened, to later describing an event that she starts to think may possibly have happened. In the later interview, not only is her language tentative, but she looks puzzled and is intermittently shaking her head no! If you don't believe me, watch the show segment for yourself by clicking on the link under the picture at the top of the post.

The key point the reader should also consider is that the experimenter has now put the subject in the position of calling her parents liars! If they are generally truthful, hearing that they reported something that seems completely alien to her whole personality will at the very least introduce cognitive dissonance and self doubt. I mean, why would her parents make up something like that? This self doubt is clearly manifested in the patient's facial expressions and tone of voice as she says the things she says in the film. 

However, even if the parents were notorious for being fast and loose with the truth or made a habit of blaming the subject for things that were not her fault (a not uncommon feature in dysfunctional families), due to family loyalty the patient might still become motivated to protect her parents' reputation to the experimenter and perhaps also to save herself from an argument with the parents later on. Family loyalty is something Dr. Shaw apparently either knows nothing about and/or has never even considered.

The subject's initial response to the experimenter relating to her what her parents allegedly said had "happened" was this:  "Honestly, I don't remember. I don't know what you're talking about. I don't think I've ever been in a fight." (She laughs). I'm so confused!" While she said this, I observed not the least bit of hesitation.

Dr. Shaw admits during the program that she uses techniques meant to create social pressure to get the subject to come up with the false "memory." Experiments in social psychology have shown that the pressure to conform to a group can cause people to say things that they actually know are not true. In other words, they blatantly lie in order to fit in. The most famous of these experiments were done by Soloman Asch, as described here.

Shaw tells the subject, "Relax, close your eyes, and focus on trying to retrieve this." This instruction implicitly assumes that the event the experimenter concocted actually took place. Then comes a little extra social pressure: "It seems strange, but it does work for most people." She then has the patient picture herself at the time and place under discussion. "Picture yourself at the age of 14 and it's Fall and you were with Ryan when it happened."

A week later, the subject starts talking tentatively, "I remember like a verbal fight." She has an unmistakable puzzled look on her face. "It seems so unlikely." Clearly, she is not really recalling any specific event, but trying to put together bits and pieces in her memory from other things that might have happened to her - again, I strongly suspect, to avoid either saying or believing that her parents have lied about her. 

She continues, "Maybe I pushed or something."

Shaw encourages her to continue. "Good! Ok!"

Subject: "I feel like she pushed [significant pause] me first. 

Feeling like something might be true is hardly the same as actually remembering it.

A week later, the subject embellishes the non-story: "I think the cops showed up." (Translation: I'm not really sure about this). "We were kind of having maybe like a verbal kind of fight and it got into a push." Maybe? Again, does not sound like a specific memory at all. And the coup-de-grace: After saying this, she again shakes her head no.

Dr. Shaw confidently asserts that she has now proven that you can induce false memories in people, when what she actually proved was that under conditions of social pressure, cognitive dissonance, and/or family loyalty issues (and probably in several other contexts), you can induce people to make stuff up. And sometimes even lie to themselves about it.

Tuesday, February 16, 2016

Reader's Therapists Disagree With Me


"Letters, we get letters
We get lots and lots of letters"



Yet another interesting letter came to me in response to my posts that make the recommendation to adult victims of abusive families that they find a therapist who can help them confront their abusive parents about the family dynamics in ways that get the parents to stop any ongoing dysfunctional interactions. 

A therapist actually fired the reader from his practice because the patient did not want to divorce her mother!

As I have said repeatedly, I never recommend that patients continue to be abused by their families. However, I do not think that divorcing your family is the only other option, and it is certainly not the best option. This is because, unfortunately, you continue to carry your parents around with you in your head for the rest of your life. 

Fear tracts and other tracts in the brain's limbic system that determine the way we all normally respond to the interpersonal environment - and that are highly resistant to fading away through the normal processes of neural plasticity - come from, and respond more strongly to, one's parents than to anything else in the environment. 

It does not take much parental contact at all to reinforce them - even once every few years might do it. Contact from other family members in which messages about the parents are provided also works quite nicely in this regard. In fact, anyone else who behaves in any way that is even somewhat analagous to the way the parents behave will also trigger and reinforce them - and the pathways are very powerful in shaping our usual behavior.

Even if you stop interacting with parents altogether, you are very likely to pass on repetitive dysfunctional interactions to your own children despite your best efforts. Often people go to the opposite extreme from their parents in the way they interact with their children, yet end up with kids with exactly the same problems, as described here. Other children from abusive or neglectful households decide never to have children themselves for fear that they might turn out acting just like their own parents.

As mentioned, divorcing a family and continuing to be abused are not the only two options. There is a third: the one I mentioned in the first paragraph above. It is certainly not an easy thing to accomplish, or patients would have done it themselves long ago. It takes a lot of patience and persistence. And doing it badly is worse than not doing it at all. Nonetheless, with one's family of origin members, where there is a will, there is a way.

Unfortunately, the majority of therapists these days do not really understand family dynamics at all, are unaware of the above risks involved in recommending a "divorce" from parents, and do not know the techniques for helping their patients overcome multiple resistances and invalidation from family members when the patients attempt to discuss family dynamics with parents in a constructive way.

Interestingly, just after a received the letter from the reader mentioned above and went on to answer it, I got an extremely nasty missive from a psychotherapist on this very subject. Perhaps it was even the reader's prior therapist. I mean, who knows? I won't mention the therapist's name, but she even signed it. The letter read:

As a therapist I can say you are an awful therapist; truly terrible. The best thing a person who has been abused as a child can do is get away from their parents, make peace with it. Suggesting that someone that has been abused, goes back to the abuser and does the work to try and repair damage is abusive and shocking. I am shocked.

This therapist apparently thinks patients who were abused as children are just too weak and damaged to stand up to their family members. How invalidating! That's probably what the abusive parents think of their adult child as well.

Anyway, here is the letter from the reader complaining about a therapist just like her. My answer is written below in amber color.

My parents abused me, physically, sexually and emotionally. As a result I
have a traumatic brain injury. I was put in foster care when I was 13. I am
now 35. I have gotten help. I am getting help still. My last therapist fired
me after I reconnected with my mother.

My mom has apologized and she has changed! It took awhile as in years but we now have a great relationship. I have a new therapist. I am scared because over Christmas I reconnected with my father who has also apologized and changed for the better. I have closure.

I have my family. I am scared that if I tell my therapist she is going to
freak on me, shame me, guilt me and or fire me. I am seeing her for help for
my own bad choices and the resulting trauma. I know she hates my family but I
don't understand how a therapist can tell me that I can change while insisting my family who they have never met can't [right on!]. It doesn't make any sense. I am not sure how to tell her.

I can't comment on your situation specifically without personally evaluating you and your family extensively, and without knowing a lot more about your experiences with your therapist, so the following are general comments that may or may not apply to you:

As you may have guessed from my blog, I am a firm advocate of my patients reconnecting with their families, even if the family had been abusive, as long as the abusive or invalidating behavior has been stopped and has been openly discussed by the involved parties, with the result that everyone has some idea of where the dysfunctional patterns came from and what purpose they had served. Before that goal has been accomplished, I coach my patients on how to get through the family’s often formidable defenses against having such conversations, so that they can get to that point.

Of course, I make sure that my patients have a safety plan for themselves (and their children if any) if this process starts to take a wrong turn, in which case we try to figure out what went wrong and how to get things back on track. I almost never give up. However, if a patient puts their child in danger (like leaving a young one with a grandfather who had sexually abused the patient as a child), we have to work on that issue first.

Unfortunately, there are a lot of therapists who still believe that divorcing one's family is the best course. My recommendation in such a case is to find another therapist. Unfortunately, therapists familiar with dysfunctional family dynamics are getting harder to find.

Also, if someone is afraid to be honest with their therapist, that in general ties the therapist’s hands, so there is almost no point in continuing. A good therapist may certainly question a patient’s decision but should never attack them personally for having made it.

Tuesday, February 2, 2016

Themes of This Blog Seen In Newspaper Advice Columns – Part III




This is the third in an occasional series of posts showing how several of the issues I discuss in this blog show up in letters to newspaper advice columnists. In order to assure themselves a wide readership, advice columnists must bring us problems that resonate with a fairly wide demographic, and they therefore provide us with another source of information about human behavior and cultural trends.

I follow Jeanne Phillips (Dear Abby), Carolyn Hax, Amy Dickinson (Ask Amy), and Marcy Sugar & Kathy Mitchell (Annie’s Mailbox).

Of course these letters leave out a lot of what might really be going on with the writer, and I will be admittedly speculating about how the behavior described in the letters may be examples of covert issues that are not being directly discussed.

Before each letter, I will discuss the blog subject that seems to be being discussed. I will also include a link to a related post. I am not including the columnist’s responses to the letters. 

*

In the following letter, a father pushes his son away by constantly telling him what a disappointment he is. The son has rejected the trappings of what the father considers successful living. It is quite likely in such situations that the "disappointing" son might be acting out the father's repressed or covert rebelliousness against the very standards the father seems to embrace. 

In such situations, the father probably does things on rare occasions that indicate to the son that the father is "getting off" on what the son is doing - but then the father rejects him as a way of rejecting that part of himself that he finds unacceptable. In actuality, those parts were unacceptable to his own family of origin.  The son then obliges by keeping his distance. Thus, this could be a possible example of the role of Avenger.

12/6/15, Carolyn Hax.  Dear Carolyn: Through the years, my husband has learned to let go of the hopes and dreams he had for his son, that he would achieve financial and social success as my husband defines it: white-collar job, nice house, nice cars, wife and family, membership to country club, all the trappings that he has achieved for himself and that represent success to him. His son, on the other hand, works in the restaurant trade (not in management), lives a pretty bohemian lifestyle but has neither been in trouble with the law nor abused drugs... Husband has never made it a secret that he feels son could have done better. Son has never married at age 40 but now finds himself the father of a child (he plans to take responsibility for the child). We want to be a part of this child’s life. At this point, the only expectations my husband has of his son is that he respond to his efforts to contact him. To no avail. Son responds on his own timeline or not at all despite repeated requests. My husband wants to draw a line in the sand over this. I think we should go with total capitulation for the sake of the future grandchild. How can I be supportive of my husband (“Yes, I understand how frustrating this communication thing is for you”) but still make it clear that I will not take part in any “line in the sand” stance? This is creating tension between my husband and me. - The Step Mother

*

In the States, we tend to think people are basically selfish and don't care what other people think, especially family members. We think kids growing up are more influenced by their peers and the media. Of course, the questions of which media a teen looks at and with which peers he or she chooses to associate with - and there is a large variety to choose from - is ignored in these formulations. The choices people make are no accident. Also, as I've pointed out many times, kids who appear to be oppositional to their parent's wants and values only do that because that is what they think the parents expect of them.

I believe people really are willing to sacrifice their own opinions and desires in order to please their parents. Of course, how much one can challenge parental values depends on how conflicted the parents are about them. In the following letter, a woman performs summersaults trying to both be her own person and please her parents at the same time. 

12/14/15. Ask Amy. Dear Amy: I have been with my partner for five years; he rents his own place and I live with my parents. My parents are old-fashioned and believe I can only live with him when we are married (I used to share this view, but now I don't). I have finished college and have moved back home to pay off my debt and save for a house (or wedding!). My partner's home is five minutes away from my workplace and my folks' house is one hour away (in good traffic), so I do frequent "sleepovers" at his place. This is causing tension in both households. I pay rent to my parents and I help out my partner by cleaning up after myself and buying bread, milk and eggs regularly. But he says that I'm using him, and that I'm just doing the minimum. He says I should be preparing dinners for both of us when I am there, doing washing, or helping by paying rent or at least one utility bill. Now I'm broke, tired and grumpy. I'm at his house cooking and cleaning, and then when I'm at my parents, I'm doing exactly the same thing to appease them because I've slept over at my partner's house. I've gone cold turkey and have slept only at one home, but then money is wasted on gas driving back and forth. I can't afford to move out and I don't want to get married just so we can live together. HELP!!! — Betwixt

*

When someone is playing a dysfunctional role within their family of origin, it can be difficult and painful. When seeking a spouse or partner, such people will often pick someone who will help them to continue to play the difficult role. They, in turn, help their spouses play a difficult role within the spouse's own family of origin. This is what I refer to as mutual role function support. It can be thought of as a form of mutual enabling.  

It is important to remember that the alcoholic enables the "co-dependent" to be a co-dependent as much as the co-dependent enables the alcoholic. The whole process is bidirectional - it goes both ways simultaneously. In the following letter, the son of a controlling mother marries a spouse who is also rather controlling, as even the advice columnist recognized. In a variation on this theme, the mother and the wife start competing with one another over who will have the most control over the poor guy. If the mother's need to control men were a bigger issue for her and her family, he might never have even become engaged in the first place.

12/15/15. Ask Amy.  Dear Amy: I have a controlling, manipulative, guilt-tripping mother-in-law-to-be! I know that each time I hear from her she is just trying to trap me into saying yes to something. These traps include trying to get me to change our wedding plans, and roping me into a jewelry party hosted by her friend (repeatedly pushing on that). She just can't understand the word "no." When I did say no she whined to my fiancé, saying it felt like a slap in the face (can you say "manipulation"?). This has to stop. My fiancé tried dealing with it by telling his mom that I will say no to some things, but I felt this was really his way of calling me "pushy." My fiancé tried the kid gloves approach and it didn't work. I decided to take matters into my own hands and texted her three examples of her overstepping her boundaries and letting her know it would no longer be tolerated. She had the nerve to say it made her "sad." Now he is having a hard time because his mom is upset. He doesn't understand that we have to back each other up, especially in situations like this. His mom is so bad that she needs a copy of his shift schedule at work because she wants to keep track of him. Maybe my approach is too direct, but so what? We are in our 40s and don't need to be under her thumb. I don't let my mom get away with this kind of behavior, and I'm certainly not letting a MIL do this. What is your opinion, Amy? — Upset

*

One of the most read posts on my Psychology Today blog, and the one which generated some of the most heated responses from reader, posed the question of whether parents who had been cut off by their adult children were really as clueless about the reasons that happened as they portray themselves to be in public. With my patients, unlike the followers of many psychotherapy schools, I always presume that people are never too stupid to notice that their repetitive behavior leads to bad outcomes - yet they continue to engage in it anyway.

The following letter is remarkable in that, while ostensibly asking advice, the mother of an alcoholic woman, who is also what I refer to as a Minnie the Moocher, admits as clearly as imaginable that "I know I've enabled my daughter for her entire life."

12/28/15. Annies' Mailbox.  Dear Annie: Our oldest daughter is married to a nice man and they have a sweet 2-year-old daughter. My son-in-law makes good money and my daughter can afford to stay home, but they never seem to have enough to get ahead. My daughter has been known to spend foolishly. They only have one car and it doesn't run half the time. They can't afford another. We let them live in our home for a year rent-free, so they could save enough to purchase their first house. I know I've enabled my daughter for her entire life. She is very spoiled and self-centered. We argue a great deal and exchange hurtful words. Regularly, I surrender to her selfishness and give her money or run errands for her, even though I work full-time. I do these things because she is a recovering alcoholic and drug addict, and I fear she will otherwise return to that life again. She doesn't attend her meetings anymore. I don't know how to handle her. I'm either forced to defend myself or give in to her whims. She never appreciates anything I do for her and she never does anything for me. Her husband is no better. He is selfish and spoiled by his mother, and he also enables my daughter. She's a good mother, but I babysit a lot. Her husband doesn't complain when she gets together with her friends, but he works long hours and they don't have much time together. I think he feels neglected. How do I know when to do things for her and when not to? How do I tell the difference between enabling and being a good mother? When she gets into one of her horrible, blaming moods, how do I handle that? This child has become a bitter pill to swallow, but I love her so much.  — Mother of a Narcissist

Tuesday, January 19, 2016

Research In Psychotherapy: Outcome Research Versus Process Research




In my Psychology Today blogpost about research in psychotherapy outcomes, and in my last book, I complained about the inflated claims of researchers in psychotherapy - particularly those made by purveyors of cognitive-behavioral therapy (CBT). They grossly overstate both the power and the significance of their results.

Unfortunately, a new report by the Institute of Medicine (IOM) falls for this baloney hook, line and sinker. The report on psychosocial interventions for mental illness and substance abuse has drawn a wide variety of responses from the field - including praise, recommendations for improvement, and some sharp criticism from psychiatrists and mental health professionals who are experts on psychotherapy. I am obviously sympathetic to the critics.

Of particular interest is that the report lauds the so-called "evidence-based psychotherapies" - code for those therapies which are "supported" by the incredibly weak psychotherapy outcome studies. One critic, Peter Roy-Byrne, M.D, summed up the criticisms of the report as follows:" In medicine, there is usually an array of different treatments for the same condition because of individual variability that is still poorly understood. Yet the field of medicine does not spend its time trying to understand what are the common elements between various effective treatments, though it will often explore comparative effectiveness as a way of improving care. It may well be that different kinds of individuals and problems demand different psychotherapeutic approaches rather than that there is one elemental Holy Grail that will be best for everyone.”

Of note is that, at least if you believe in free will as I do, patients always can choose to either respond favorably or unfavorably to any intervention a therapist makes. It is just not all that predictable, because everyone can choose to respond differently. In fact, the very same intervention given to seemingly very similar patients can lead to responses that are completely opposite from each other - in one case the patient improves on some dimension, while in the next the patient may get worse! In psychotherapy, patients are very different from one another in ways that vastly outnumber individual differences that affect treatment outcomes in any other field of medicine.

Holly Swartz, M.D., of the Department of Psychiatry at the University of Pittsburgh School of Medicine, brings up another criticism of the IOM report: “The recommendation to reduce highly complex interventions to their component parts, however, is misguided. A bias toward CBT and CBT-based interventions constitutes an essential flaw in the IOM report, placing affect-focused therapies such as IPT (interpersonal therapy) at risk for unfair negative evaluation and, ultimately, elimination from our therapeutic armamentarium. … [T]he IOM report should advance an inclusive research agenda that reflects and supports the diversity of psychosocial interventions that the IOM purports to represent.”

Yet another problem with the IOM report and similar viewpoints is that they completely ignore the fact that there is a vast literature within psychotherapy research that does not focus on outcomes but on process. Process research looks at the moment to moment interactions of patients and therapists within the context of their particular relationship.

As Les Greenberg, Ph.D, puts it, "Research on change processes is needed to help explain how psychotherapy produces change. To explain processes of change it will be important to measure three types of outcomes—immediate, intermediate, and final—and three levels of process—speech act, episode, and relationship. Emphasis will need to be placed on specifying different types of in-session change episodes and the intermediate outcomes they produce. The assumption that all processes have the same meaning (regardless of context) needs to be dropped, and a context-sensitive process research needs to be developed. Speech acts need to be viewed in the context of the types of episodes in which they occur, and episodes need to be viewed in the context of the type of relationship in which they occur.

Speech acts refers to the fact that speech does not merely convey information to, or exchange propositions with, a listener. Sentences do things that are frequently independent of the meaning of the actual words that are used. Speech causes others to perform acts. If I say, "I hear you're having a party Saturday," I am not describing only my recent experience of having heard about the party. I am probably fishing for an actual invitation. In all likelihood, I have made in advance a determination that this sort of statement is the best way to accomplish my goal of attend­ing the party. I have made a prediction about the future behavior of the listener. If this particular ploy leads to no response or a different response, I will consider alternative strategies.

Those who tout psychotherapy outcome studies, which study psychotherapy interventions as if they occurred in some sort of relationship vacuum devoid of context, seem to want to pretend that the highly significant process research literature does not even exist. In fact, the vast majority of articles published in the journal Psychiatric Research are process studies, not outcome studies.