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Tuesday, September 16, 2014

Faking Psychiatric Conditions for Fun and Profit


The nurse was on to McMurphy's ruse...because she was actually paying attention


A story from the New York Times on  August 27, 2014 caught my eye:

“Ex-Police Officer Pleads Guilty to Playing Role in a Disability Fraud Scheme  By JAMES C. McKINLEY Jr.

A former New York City police officer accused of playing a major role in a scheme to defraud the Social Security Administration pleaded guilty on Wednesday and agreed to testify against his co-defendants. Prosecutors said that the former officer, Joseph Esposito, was one of four people who concocted a scheme that bilked the federal government out of more than $27 million. 

The group allegedly helped scores of police officers, firefighters and other city workers obtain disability benefits by feigning mental illnesses, in some cases by falsely claiming they had been psychologically scarred by the terrorist attacks on the city on Sept. 11, 2001…

Court papers… described Mr. Esposito’s role as pivotal. He recruited many of the people who applied for the benefits and introduced them to three others accused of helping to run the operation …referred most of the applicants to two psychiatrists for treatment and to establish a year’s worth of medical records. On several telephone calls recorded by the authorities, Mr. Esposito was captured coaching applicants on how to mimic the symptoms of depression and post-traumatic stress when being examined by doctors…

With diagnoses and treatment records from the doctors in hand, Mr. Hale and Mr. Lavallee would complete and submit applications to Social Security, using stock phrases like “I don’t have any interest in anything” and “I am up and down all night long.”

Psychiatric symptoms cannot be measured objectively under the best of circumstances.  Doctors must rely on patients' self reports or on how they appear in the examining room. And people can be excellent actors in situations like this without ever having taken an acting lesson in their life.  Faking a psychiatric syndrome is in most cases extremely easy to do.

So it does not necessarily follow that a psychiatrist is not doing his job correctly if he or she is deceived into thinking a patient meets DSM criteria for one disorder or another.  This is especially true when a patient is only seen in the doctor’s office, where an appointment may last a relatively short time. It is obviously more advantageous if a psychiatrist has a way of observing patients when the patients do not realize they are being observed.  In a hospital setting, for example, patients may let down their guard during a quiet afternoon spent socializing with other patients, and not realize that a nurse is watching them out of the corner of her eye.

However, the job of the schemer/faker has gotten considerably easier, whether they are trying to fake a disability claim, looking for an amphetamine prescription, or even trying to enroll in a study for which subjects get paid. This is because diagnostic interviews have gotten shorter and shorter, and doctors have begun to rely on the use of shortcuts such as symptom checklists – two things that I have been ranting about frequently on this blog. 

Under these circumstances, dishonest patients do not have to worry much about being caught in an apparent contradiction, nor do they need concern themselves with describing their symptoms in detail in a way which might seem to the examiner atypical for the condition they are faking. The doctors ask no follow-up questions, the answers to which might then raise suspicions that they are possibly being duped.

The use of the all important follow-up questions is particularly vital in sorting out the clinical significance of a psychiatric symptom that may seem to be present. A good psychiatrist functions much like a good investigative news reporter.  He or she can look for signs that the patient does not know exactly what the doctor needs to know, is exaggerating symptoms, or is possibly making some unspoken assumptions. The doctor can then ask for further clarification, which is an excellent technique for unmasking possible fabrications or half-truths.

Another recent trend that makes it easier for a patient with a hidden agenda to fake a psychiatric disorder is the tendency of some doctors to type away on an electronic medical record while the patient reports his or her symptoms - instead of making eye contact with the patients and observing them carefully while they talk. Cues to fakery that involve facial expressions and body language will of course be missed.  Not to mention that the doctor's attention is being split between two tasks instead of just one, making all clues to dishonestly less likely to be noticed.



Of course, even a doctor who does a real and complete diagnostic interview the way it is supposed to be done can still be faked out. But doctors who do not do one are far more likely to be duped. Apparently, many of them do not really care if they are – as long as they get paid.

Tuesday, September 9, 2014

Corruption of the Evidence Base in Evidence-based Medicine




"‘Published' and ‘true' are not synonyms" ~ Brian Nosek, psychology professor at the University of Virginia in Charlottesville

Publish or perish. Obtain outside funding for research or lose your teaching position. 

Academic medicine and psychology have always been like that to some extent, but it’s been getting worse and worse lately. It’s a wonder anyone wants to become an academic these days. In academic medicine, there has also been a new push: invent something you can patent like a new drug or device that will make a profit for the University.

Is it any wonder that some academics start cheating when their livelihoods depend on it and they are under this sort of pressure? Or that business interests would try to take advantage of their plight to enhance their own sales and their bottom line? This sort of hanky panky had been increasing at an alarming rate.

Now of course, I am not arguing against the practice of doing clinical research and randomized controlled studies of various treatments, or against experimental psychology. These activities remain important even in light of all the corruption that is going on. It is one of the major differences between real scientists and snake oil salesmen, like those we see in much of the so-called “complementary and alternative medicine” industry. And just because a study is industry funded, that does not automatically mean that it is dishonest and not to be trusted.

What the increasing level of corruption means is that we have to pay more and more careful attention to the details of the studies that do make it into print.

First, we have to be on the lookout for outright fraud. An article published in the Proceedings of the National Academy of Science by Fang, Steen and Casadevall (October 16, 2012, 108 [42], pp. 17021-17033) found that the percentage of scientific articles that have been retracted because they were found to contain outright fraudulent data has increased about tenfold since 1975!

Journals also retract articles because of problems with a study that do not involve actual faking data, but the Fang article found that only 21.3% of retractions were attributable to innocent errors. In contrast, 67.4% of retractions were attributable to misconduct, including fraud or suspected fraud (43.4%), duplicate publication (14.2%), or plagiarism (stealing other people's material) (9.8%). 

The authors also found that journals often soft-peddle the reasons for any retractions that they do make. Incomplete, uninformative or misleading retraction announcements have led to a previous underestimation of the role of fraud in the ongoing retraction epidemic. Zoe Corbyn of the journal Nature opined that authors and journals may use opaque retraction notices to save face or avoid libel charges.

Second, we have to pay more attention to the design of the studies, the outcome measures used, and the statistical tricks employed to arrive at the study’s conclusions. We have to look to see if the abstract of a study, which is what most practitioners read if they read anything at all, actually summarizes the findings correctly

We have to look closely if the results are suspect because of the way the sample of subjects was selected and/or screened. I described in a previous post an excellent example of authors completely mischaracterizing the sample of subjects in a journal article published in the premier medical journal of our times.

Research in psychology and psychiatry has problems that are unique to those fields and which are very important. In fact, Cook and Cambell in their book (Quasi-Experimentation: Design and AnalysisIssues for Field Settingspoint out that randomized trials in our field are not really truly experimental in the scientific sense, but are instead what they call “quasi” experimental. 

This is primarily because of a major problem in such studies that concerns the nature of subjects selected for a study.

People are by their very nature extremely complicated. True scientific experiments must assign subjects at random to various treatment or placebo groups. However, in the social sciences, subsets of research subjects are very likely to differ from each other in many ways other than the presence of the treatment whose effects are being tested.

Conclusions from studies about cause and effect are much more complicated in psychiatry and psychology than they are in, say, physics. In physics, the matter under study is isolated from external sources of influence. Obviously, most controlled studies in medicine do not keep the subject under wraps, and under the complete control of the experimenters, for months at a time. 

Second, in physics, other variables that change over time can be kept out of the experiment's environment. Not so with aspects of people’s lives. Third, measurement instruments in psychology are often based on highly subjective criteria such as self-report data or rather limited observations interpreted by the experimenter.

Cook and Campbell also show how experimenters can manipulate the subjects in ways that can determine in advance the results they are going to get. This is because experimenters are usually dealing with variables that are distributed continuously rather than classified as one way or the other on the basis of some discreet characteristic. As examples, how much does someone have to drink in order to be classified as an alcoholic? How often do you have to engage in risky impulsive behavior to be classified as having poor impulse control?



Both potential causes and potential effects in psychology and psychiatry are distributed in the usual manner - in a bell-shaped distribution curve. Let's say that the variable (on the "X axis") above is how often subjects engage in risky behavior. Some people will rarely do so, others will do so often. Both extremes are seen infrequently in the populatiom, however. Most people fall somewhere in the middle. So in determining whether one group of subjects (say people with a certain diagnosis) are more prone to risky behavior than another, where should we draw the line on the X axis in determining who has a problem with this and who does not?

As it turns out, a potential cause for any given effect can appear to be necessary (the effect never appears unless the cause does), sufficient (the presence of a cause alone is enough to produce the effect, although other causes may produce the effect as well), both, or neither in a given experiment depending on where the experimenter chooses to draw the line for both the cause and the effect in determining whether they are present or absent, as shown in the following graph:



At points A, the cause appears to be both necessary and sufficient. If points B are used, the cause appears to be necessary but not sufficient. Dichotomize the variables at points C, and the cause appears to be sufficient but not necessary! A tricky experimenter can use this knowledge to design the study in advance to get the results he or she wants to get.

In fact, there are probably no necessary or sufficient causes for most medical and psychiatric conditions, but only risk factors which increase the likelihood that a condition will appear. To steal an analogy from another field of medicine, there will always be people who smoke a lot but who do not get lung cancer, and there will always be people who never smoke who do.  

Tuesday, September 2, 2014

The Individual or the Family for Psychotherapy?




My interest as a therapist has always been finding what is called a "metatheory." Psychological theories, particularly those which try to explain why people who seek therapy are often so self-destructive, tend to focus on just one aspect of the problem almost to the exclusion of many other important considerations. 

In looking at patients, therapists from different "schools" of therapy that deal only with individuals focus solely on just one of the following: environmental factors which seem to trigger the behaviors, thoughts that are irrational and lead to counterproductive feelings and behaviors, seemingly inappropriate affects, or internal conflicts which pit one’s biological urges against values learned and internalized from one’s family or culture. 

Psychiatrists these days tend to focus just on biological and neurological processes.

Therapists with training in social psychology or family systems theory may look at either the family dynamics or at larger sociocultural influences.

There are mental health professions who are trying to counter this myopia (also called reductionism) and who would like to integrate all of these viewpoints. The typical metaphor employed by those folks is the famous story of the blind men and the elephant. One blind man feels the tail of the beast and makes conclusions about what the elephant looks like based solely on this, while others feel other parts of the elephant such as the hind quarters or the trunk, and make conclusions about the what the elephant might look like from those alone.

Some "integrationists” want to look at the whole elephant, so to speak, but are overly cautious about it. They stick to just looking for commonalities among the theories of the various blind men, rather than the whole picture. They are afraid that "integrated" therapy would be just one more school. This is reflected in the absurd name of their organization: Society for the Exploration of Psychotherapy Integration (SEPI). 

In other words, do not actually integrate anything, just "explore" the possibility. Luckily, there are a few members of SEPI who want to understand the whole elephant as a complete unit unto itself. I count myself among their number, and am part of something called the Unified Psychotherapy Project.

My main theory, which is the force behind the type of psychotherapy I do with those of my patients who present with repetitive self-destructive behavior patterns -  I call it Unified Therapylooks at the relationship between individuals and their internal processes, and the processes of the social groups to which they belong. Many of the conclusions I have drawn are based on the following series of propositions:
1.            The relationship between a self and its social system is not a constant but a variable.
2.             As children get older, their "self" differentiates from it social system - in most cases his or her family of origin - in a process known as separation-individuation. In other words, children gradually gain the ability to separate and express their own intellectual and emotional functioning when it is different from or disagrees with that of most of their family members.
3.             All individuals go through this process as they negotiate the passages of individual development whether they want to or not.
4.     Human culture has evolved over history so that, at each stage of human childhood and adult development, individuals have been able to differentiate more and more from the collec­tive as they go through the process of separation-individuation. The overall balance between individual expression and group conformity has, at least in developed countries, gradually shifted over history towards the former.
5.             Consensual validation from other members of the family system is necessary for  individuals to feel comfortable expressing individuated behavior, also called self-actualization.
6.             Because individuals have an inborn biological propensity to concern       themselves with the survival of the species, they are willing to sacrifice themselves, or aspects of themselves, in order to further what they perceive to be the greater good of their own family and ethnic group (kin selection).
7.             When individuals find that certain differentiated aspects of self seem to threaten the immediate representatives of the species, the family system, they will attempt to sup­press or completely sacrifice those self-aspects.
8.             In order to do so, they develop a false self, or persona, which is then maintained by a variety of self-suppressive devices such as self-scaring through the irrational thoughts catalogued by cognitive therapists (catastrophizing for example)- also called self-mortification - and through the use of the traditional defense mechanisms catalogued by psychoanalysts like Anna Freud. The de­velopment of a persona often causes individuals to appear to be incapable of certain kinds of activities, which makes them appear to be defective in ways that they are not.
9.             The needs of the family system to respond to the cultural forces which seem to mandate the evolu­tion of increased self-actualization often conflict with the needs of the system for stability and predictability (family homeostasis).
10.              Younger members of the family are often induced by the needs of the larger culture to behave in a fashion that is far more differentiated than the behavior of the parents. The parents, who are the leaders of the family system and its most important constituents, may be unable to com­fortably tolerate such behavior, even when they are them­selves attracted to it. The whole family system becomes threat­ened.
11.              This problem often cannot be solved in ways other than through the sacrifice of the younger system members' individuality because of two factors: the tendency of fam­ily members to protect one another from anxiety and shame, leading to an avoidance of discussing what is going on between them (metacommunication), and secondly, the tendency of family members to rely on past experience in evaluating new family behavior, leading to the so-called game without end.
12.             These factors not only lead to impaired individual func­tioning but hamper the family from adjusting to new cul­tural contingencies. The efforts of individuals to protect one another, in particular, lead to eventual harm for everyone. I call this the altruistic paradox (or sometimes the Mother Teresa paradox).


A therapist can help solve the problem of self-sacrifice by work­ing with individuals and teaching them how to avoid the difficul­ties that lead to impaired family problem solving. The pioneer in this approach was Murray Bowen. He used education, logic, and collaboration to coach his patients on how to deal differently with their families. However, what he tought them often involved techniques other than education, logic, and cooperation. 

In Unified Therapy, the  ther­apist instead teaches patients to adopt a problem-solving ap­proach with their families.
Specifically, patients can learn to overcome both their own and their family's resistances to metacommunicating about family difficulties. They can learn to bring up systemic problems in ways that do not induce negative reactions from other members of their family systems. The keys to effective metacommunica­tion are empathy, avoidance of moralistic blaming behavior, and respect for the integrity and potency of all family members.

In therapy, patients come to an expert to learn how they are induced by the reactions of others to behave in self-destruc­tive ways and why the others behave in the ways that they do. Patients learn to empathize with and understand the reasons for the negative behavior of other system members without agree­ing that the behavior is good and without sacrificing their own thoughts or emotions.

They learn to differentiate between emotional reac­tivity and emotional reactions. They learn to tolerate and to sub­vert attempts made by other family members to stop them from proceeding in the task of metacommunicating. They have an op­portunity to practice what they have learned by role playing with the therapist.

Specifically, the patient is trained to deal with various maneuvers that the rest of the system uses to get them to shut up and not challenge the rules by which the family operates. These maneuvers represent attempts to withdraw consen­sual validation from the patient and include such things as accusations of self­ishness, changing the subject, unreasonable behavior, double binds, blame shifting, nitpicking, overgeneralization, mental gymnastics, and fatalism. 

The patient is also trained to prevent family members from uniting in various combinations to defeat the patient's efforts to metacommunicate. Once the systemic problem has been dealt with, mal­adaptive and self-destructive behavior problems begin to disappear, along with many types of anxiety and mood symptoms

Tuesday, August 26, 2014

The Culture Wars, Parental Guilt, and Out-of-Control Children: The Dilemma




 


The following post comes mostly from chapter 2, Don’t Blame Us,  of my last book, How Dysfunctional Families Spur Mental Disorders:

The women’s movement in the United States, combined with economic changes that made surviving on only one income increasingly difficult for families, led to one of the fastest and most massive cultural shifts in history. Almost overnight, women entered the workforce in huge numbers. Female ambition was fully unleashed for the first time ever, and flourished. However, women who wanted to get to the top in their field in business or the professions ran into a roadblock. 

They found that, in the business and professional worlds, they were expected to act just like the men in one respect. They could not use the needs of their children as a reason for refusing to put in the long hours necessary in today’s economy to climb the corporate ladder. The United States had during this same period of time grown to become the most workaholic country on earth, eventually surpassing even Japan.
         
Women who wanted to and who were told that they could “have it all” by the ambient culture found that doing so was not as easy as some famous women made it look. Since their husbands were only just beginning to share in child care, and were as much or more involved with their careers as they had ever been, who would be around to take care of the children? Horrific stories about bad things happening to children left to their own devices and locked in their homes without parental supervision after school (deemed latch-key children by the media), began to circulate widely.

Debates over working mothers became one of the most important theaters of operations in the culture wars that continue to rage on to this day. Reactionary forces that never believed in equality for women in the first place began to spout off about all the damage being done by working mothers to their offspring. The voices of people like Phyllis Schlafly, a career woman who made a career out of attacking career women, became louder and more shrill. Unfortunately, researchers in major academic centers began to give more ammunition to voices like hers.

Widely publicized studies showed that children in families in which at least one parent stayed home with them did, on the average, better in life on some dimensions than those children from families in which this was not the case. Of course, many children from two-career families do splendidly or even better than many of their more closely parented peers, while many children of stay-at-home mothers often fail spectacularly in life, but the press ignored the scatter and put most of its focus on the “average” end result.

Of course, many families were able to negotiate the cultural changes successfully and continued to calmly set limits with their children while encouraging them to have egalitarian attitudes towards gender roles. Many others, however, were just feeling overcome by too much guilt to do that.        

The most devastating source of guilt: Many career women found that they were faced with considerable criticism about their choices in life from within their own families. The baby boomers, who were the first large wave of career women, had themselves been raised by parents from the World War II “greatest” generation. This earlier generation of women had been, on the whole, raised to conform to the old female gender role stereotypes. 

They were taught that they supposed to be totally fulfilled by being nothing but wives and mothers, as their mothers had been before them. However, as I described in the post of 9/21/11, unlike their own mothers, some of these women had had a taste of career fulfillment during the war, but had to give it up at the end of the war. 

Since these women had been raised from birth to believe in the old roles, they accepted their fate, at least on the outside. Inside, many of them subconsciously resented having to give up the excitement of their careers. Some carried this covert resentment with them for the rest of their lives. As parents are wont to do, they tried to vicariously experience what they were missing through their children. 

When they had daughters, they often pushed the girls to go out and get what had been denied to them – a satisfying career. Perhaps it was no accident that the baby boom generation was at the forefront of the feminist movement of the1960’s. Feminism had been an undercurrent in society for decades before then, but “women’s lib” virtually exploded.

As the female boomers hobnobbed with one another and talked among themselves about how women could now do anything they wanted, many faced a rather disturbing negative reaction from both of their parents when they spoke about this at home. The parents would suddenly become hostile and/or withdrawn, sometimes for no apparent reason.

Many male boomers, on the other hand, were the objects of some strange reactions from their parents as well. They had started to realize that sharing the burdens of being the family breadwinner was not such a bad idea after all. However, their fathers seemed to think less of them if they were not dominant over their wives, especially if they earned less money than their wives. 

In the meantime, some of their mothers acted helpless and dependent around them at times, but because of the mothers’ covert resentment at males for keeping them from pursuing careers, emasculated the sons who tried to take care of them in any way. 

For example, one of my patients told of an incident in which his World War II generation grandmother fell in the bathroom and broke her hip. When my patient tried to come to her aid, she refused to unlock the bathroom door. She said that she "did not want to be a bother."

These parents were not being mean-spirited when they acted like this. The parents had grown up with certain gender role expectations and believed in them. They also worried, because of their own experiences, that successful women might have a difficult time finding a mate. They believed that men would find feminists too aggressive, and in any event would be threatened by any female who might be too able to manage her own life and finances without a husband. 

These fears were stoked to near hysteria among both the boomers and their parents by a story in Newsweek in 1986, since discredited, which purported to show that college-educated women who were still single at the age of 35 had only a 5 percent chance of ever getting married.

More important than the possible reactions of male chauvinist peers, the parents of the boomers, just like their children, worried about what might happen to their grandchildren if one of their parents were not in the home to raise them as much as in past generations. How would such children fare in life?

In addition to this concern, a covert but pernicious issue lurked in the back of the minds of a significant number of the former riveting Rosies. When their daughters became successful in business, the mothers were reminded of what they themselves had given up right after the war. They had pretended for many years that having given up their jobs was really no big deal to them. Some became quiet, some became depressed, and others became actively critical of their daughters’ ambitions, especially when grandchildren came into the picture.

Boomer females were extremely confused by their parents’ mixed message that seemed to say to them, “I’m so proud of you for your career success, but stop doing what you’re doing.” Many were left with a highly unsettling feeling caused by this strange lack of support. They wanted and planned to go on with their careers, but somehow they did not feel quite right about it. They became somewhat confused about exactly what their role in life should look like. 

Men found that they were criticized by their girl friends if they opened a car door for a woman - or if they did not. Accompanying the role confusion for both sexes was the nagging, unnamed sense of guilt about their children that was mentioned above, which was then further increased by the other cultural developments.

Paradoxically, the existence of parental guilt of this magnitude had effects on parenting behavior that may be the real reason why children of two career families do slightly worse on average than those with stay-at-home mothers. Changes in parenting styles driven by guilt are probably far more destructive to children than the fact that both parents are working per se.

All of this confusion and ambivalence created two different groups of women who, while superficially polar opposites from one another, shared the exact same conflict. One group had careers but covertly envied the stay-at-home mothers, while a second group stayed at home with their children but covertly envied the career women. The latter group also had quite secret - or so they thought – deep-seated urges to escape the drudgery of doing housework and shuttling children around all day long.

Many parents in two career families worried covertly but obsessively that they were short-changing their own children. Some stay-at-home mothers, on the other hand, subconsciously worried that their hidden resentment over their burdens and their choices in life might adversely affect their children. In response, both of these groups began to monitor their children carefully or any sign of distress that might indicate even the slightest parental failing. A good percentage of them became so obsessed with their children that they spent every spare moment with them, often at the expense of their marriages.


This popular Facebook meme advocates gross over-parenting, and following this advice often leads to disastrous results.


For the career women, the guiltier they felt, the more concerned they became with turning any time they did spend with their children into “quality time.” They tried to make up for their frequent absences to their children by catering to their every whim. The stay-at-home mothers began to do the exact same thing. They also became overcome with guilt as their resentment over the perceived drudgery of their life, as well as their hidden desires to escape from it, built up over time.

Everything that happened in the home began to center around the children. John Rosemond’s nightmare world of non-traditional parenting was born.


Tuesday, August 19, 2014

The Culture Wars, Parental Guilt, and Out-of-Control Children: Introduction




The popular parenting advice columnist John Rosemond writes about an epidemic of poor parenting practices that has been accompanied by an epidemic of out-of-control children. For instance, he notes that behavior such as children biting their parents has become increasingly common. 

In a recent column in the Memphis newspaper (8/31/14), he noted that in cases of parents whose children are disrespectful and refuse to do what they are told, the parents often are not actually telling their child what to do. Instead, they are “…pleading and bribing and bargaining and cajoling and encouraging and then, when all that fails, demanding and threatening and screaming.” 

He points out that there is a huge difference between saying “You could really help mommy out by picking up these toys” versus “I want you to pick up these toys right now.” If the child asks "Why?" he recommends the old standby, "Because I said so!" He correctly points out that children will usually, although of course not always, do what they are firmly and unambiguously told to do.

It seems that whenever anyone dares to point out that that maybe the problem in cases of out-of control, temper-tantrum-throwing children is not the child but the parents, they are often met with rage and accusations of “parent bashing.” This is accompanied by protestations that their child is in some way a problem child who was, I guess, just born that way. 

Such parents will react this way even when their children are running wild in a restaurant or in a store or even in church, and it is blatantly obvious to anyone who has eyes and actually looks that they are doing absolutely nothing to control the kids' behavior.

A good example of such an angry response was seen in a recent column by advice columnist Amy Dickinson. In an earlier column (6/30/14), Ms. Dickinson had responded to someone who asked about the best way to advise a parent with an out-of-control child with the following:

 Talk to them about it and be supportive and uncritical. This is not a mutually exclusive concept. Tell them, "You can turn this around. Do you want to hear some of the things that have worked for us?" At the risk of providing yet another resource your sister-in-law will ignore, I highly recommend the work of Jo Frost, the ‘Supernanny.’ She enters households like your sister-in-law's, diagnoses the family dynamic and then offers sound and practical fixes.”

After she published that letter, another letter writer responded (7/15/14):

Dear Amy: "Perplexed" sounded like a sanctimonious parent with two "perfect" children, complaining about a family member with a typical tantrum-throwing 3-year-old. I can't believe you didn't call him on this. — Not Perplexed Parent

While toddlers of course do sometimes throw tantrums, parents routinely letting them run wild and doing absolutely nothing at all about it is something else entirely. Ms. Dickinson wisely responded that she “…felt sorry for the tantrum-throwing little boy whose parents let him rule the household and then worried about his behavior. Calm and confident parenting would benefit this child, and I hope the parents get a clue.”

When out-of-control children escalate their behavior, in some cases things can get really out of hand due to a variety of factors that differ somewhat with each particular family. Parents may in frustration start to become abusive verbally and/or physically, or they may just abdicate their role as parents completely – something known in the literature as biparental failure. Or do all of the above at different times.This latter pattern can be the beginning of a process by which a child starts to develop borderline personality disorder.

These problematic parental practices seem to be becoming more and more common. What is behind this? The explanation I have proposed, as I have discussed briefly in previous posts, is that there has been a relatively sudden - on the adapting to cultural changes time scale - and all-encompassing cultural shift that has led to a dramatic increase in the level of guilt among parents. The guilt has in turn led an increasing number of parents to become over-solicitous of and afraid to discipline their children. The kids act out in response, which then causes the parents to get angry with them.

What is this shift? Well, it’s the all of the elements of the cultural upheaval that happened during the infamous 1960's. In particular, it was the emancipation of women combined with economic changes that made surviving on only one income increasingly difficult for families. 

Now don’t get me wrong. The emancipation of women is of course one of the greatest things to have ever happened, as are most of the other changes that occurred during the sixties: civil rights for minorities, the revolt against mindless conformity, and the sexual revolution.

So it is not the new freedoms themselves that are the problem, but the reactions of people to the changes, and the difficulties some families have in adjusting to the new cultural contingencies. As many pundits have pointed out, we are still even now fighting over the sixties. Almost constantly. It is referred to as the “Culture Wars.” It’s part of the reason we have “red” states and “blue” states on the election maps of the United States.

For example, many people still have not got the message that the sexual revolution was won by the revolutionaries. Surveys show that around 90% of both men and women today are not virgins when they get married. And that’s just the people who will admit that. However, you would never know that from listening to the abstinence preachers. 

And of course we have those people who give lip service to encouraging abstinence while somehow still recommending that we should be more “realistic” about the fact that teenagers are going to have sex and therefore we should teach them birth control. They cannot bring themselves to say that having sex responsibly is really just an OK thing to do.

A lot of people continue to feel the need to lie about sex. Anyone really think the Jonas Brothers pop group kept those promises with the “promise rings” they wore, when they were constantly being besieged by legions of groupies? And some promise ring wearers admit that they do not consider oral sex to be “sex.” How bizarre is that?

In fact, there are still many casualties being generated from the sexual revolution of the sixties, even though it’s been over fifty years. One wonders if all the people having unprotected sex do so as a way of punishing themselves for having sex because they feel guilty about it. 

They like to make excuses for being careless, such as saying that condoms interfere with their “spontaneity.” Well perhaps, but so does an unplanned pregnancy or an STD. The real issue is that these people still cannot tell themselves and others that they believe deep inside that they are not doing anything wrong.

I recall a middle aged divorcee I saw for therapy, the son of a minister, who was trying to justify the fact that he had sexual relations with a woman he went out with. I asked him, “So are you saying you don’t really agree with the teachings of your church on this issue?” He replied that the teachings were absolutely correct, but then added, “It’s just that I have these needs…” (Therapists should definitely not face palm during sessions. I didn't but I sure felt like it).

I mentioned the time scale by which individuals and families adapt to cultural changes. The process moves a lot more slowly than most people realize (cultural lag). After all, people are raised by parents who grew up in a somewhat different time. The parents, in turn, were raised by grandparents who grew up in yet another different time. And so on and so forth. Old rules get passed down from one generation to the next, even when they have become obsolete and counterproductive due to cultural shifts.

The rapid cultural changes in gender roles during the last few decades is what I believe to be behind all the parental guilt that we are seeing today, and which have led to the problematic parenting patterns which seem to be increasing in prevalence.

It is hard to believe that just four or five generations ago, even in advanced industrial countries like the United States and England, women were treated in ways that are not all that much different from the way they are treated today in highly traditional Muslim societies like Saudi Arabia. Just the other night, on the Ancestry.com plugfest television show, Who Do You Think You Are (on TLC, formerly on NBC), actress Cynthia Nixon discovered that her 3X great grandmother, Martha Curnutt, killed her abusive husband, Noah Casto, with an ax in 1840s Missouri.

Actress Cynthia Nixon on Who Do You Think You Are?

The show’s narrator explained that she did not really have much choice. The law would not protect her, and her husband apparently told her in no uncertain terms that he was going to kill her. It was not just that women did not obtain the right to vote for another 80 years (in 1920 in the US – less than three generations ago). They were completely at the mercy of their husbands. The narrator explained that in United States until the late 1800's wives were ruled by a legal doctrine called coverture. 

Coverture stripped women of almost all civil rights upon marriage, and they were considered legally indistinct from their husbands. Women could not keep any money they earned, own property, sign legal documents, serve on juries, get educated without their husband's consent, or retain custody of their children in the event of divorce. Men were legally allowed to physically punish (although not kill) their wives, and wives had no legal right to refuse sexual relations.

Some aspects of coverture lasted until the 1960's in some states. In fact, it was not until 1973 that women could serve on juries in all 50 States.

Flash forward to the 1950’s - in my lifetime. When I was a child very few married middle-class women had careers. Children could play outside freely without fear of strangers coming into the neighborhoods because their mothers were almost all home, and were all looking out for all the kids behind the scenes. These mothers were the granddaughters of the women that were ruled by coverture! 

Despite the mothers mostly all being at home, kids were seldom actually actually spending a lot of time with their parents. They kept busy playing with each other. Since I grew up in sunny Southern California, it was almost always nice enough to play outside, and that is where we all were sent. And a lot of it was free play, not organized activities - although there was Little League if you liked that sort of thing.

These mothers, who came of age in the thirties and forties, had no idea what was about to hit them when their daughters became college aged and joined the "women's lib" movement en masse.

In my post about the family dynamics of borderline personality disorder from 9/21/11, I discussed the peculiar situation of these women, who as Rosie the Riveter types got a taste of what it was like to have a career, only to sent back to the kitchen with advice from the government to get barefoot and pregnant again at the end of World War II.  



As mentioned, their daughters came of age during the Women’s Lib movement, which set up a real “generation gap.” I discussed how those developments led to tensions which spilled over into the future parenting practices of the younger of the two generations. I would refer the reader to that post, as a prelude to part 2 of this one, which will discuss the details of the individual and family dynamics that have been creating today’s dysfunctional parenting styles.

Tuesday, August 12, 2014

If You Deny Your True Feelings, Your Children Might Just Express Them for You




A Dialectic Perspective On Defense Mechanisms.

In my post of February 11, 2011 on dysfunctional family roles, I described the roles of the savior and the avenger.  In families in which children play these roles, a parent is suppressing and/or denying strong impulses or desires which were unacceptable within the family in which the parent grew up. The parent tries, more or less, to ignore these impulses or even to pretend that they never existed.

In the case of the savior, the child acts out the parent’s repressed ambitions. In the case of the avenger, the child acts out the parent’s repressed anger and hostility. 

The above picture is a skit from the comedy duo Key and Peele doing an impression of President Obama. The President gets to act all cool and collected while his “anger translator” goes off the deep end.  This symbolizes exactly what such kids are actually trying to accomplish.

Why and how do children end up doing this?

To start with, trying to deny or ignore one’s strong emotions or urges unfortunately does not make them go away. This just plain does not work. This fact sets up what psychoanalysts call an intrapsychic conflict. The repressed urges and feelings press for expression, while the person who has them attempts to fight them off in one way or another. 

The analysts focused mostly on the individual’s mental gyrations, called defense mechanisms, by which people with intrapsychic conflicts compulsively attempt to ward off the undesired aspects of themselves while still covertly allowing themselves some hidden expression of those very aspects.

Although the analysts were wrong about a lot of things, they were certainly on the right track with the concepts of intrapsychic conflict and defense mechanisms. Those are quite real, and are universally recognized by people in our culture in their everyday lives - even by those psychologists who claim they do not exist!  

Even cognitive behaviorists have been known to shout at someone, “Don’t take your frustration out on me!”  That means the frustrated person is relieving himself of the feeling of frustration by redirecting it to someone that the person is not afraid of. This is the defense mechanism called displacement.

What the analysts missed are some of the interpersonal effects of defense mechanisms and their ramifications. It took a whole different school of therapy, family systems, to point out that repressed and warded off feelings in a parent can directly induce their children to act out those unacknowledged feelings. 

Of course, family systems therapists had to distance themselves from the psychoanalytic therapy that was the predominant paradigm when they started out. So they repaid the analyst’s favor by not acknowledging the role of the parent’s intrapsychic conflict and its aspects within the individual.

The dialectic perspective tells us that a mental phenomenon is neither exclusively an intrapsychic phenomenon nor  an interpersonal phenomenon, but both simultaneously. In fact, in general the dialectic perspective consists of the concept of both/and as usually being preferable to either/or. To fully understand psychology, we have to look at phenomena from a variety of perspectives and try to integrate them into a unified viewpoint. In today’s fragmented field of clinical psychology, an integrated, unified viewpoint is what is often sorely lacking. 

There are some of us trying to work on that (See the Unified Psychotherapy Project for more information).

So let’s get back to our repressed parent. The denial of strong feelings or urges leads people, in response to certain aspects of their family environment, to behave in a somewhat unstable way. They may appear to other family members to be highly emotionally disturbed. This affects the other family members and often leads to highly charged, dysfunctional interpersonal reactions by the whole family group.

Since group survival depends most on the functioning of the group leaders – the parents - having unstable parents frightens children. They consequently are induced to try to find ways to behave that seem to make the family interactions at least somewhat smoother. This does not mean that the interactions will become truly smooth by any means. Just more predictable and somewhat more stable. The process by which all family members strive to keep the behavior of its members within certain bounds is called family homeostasis by family systems therapists.

If the child acts out or expresses the parents’ repressed urges, the parent often calms down.  

As I explained in the earlier post, parents frequently live vicariously through identification with their children. When their children do what they themselves are afraid to do, it allows for some expression of their repressed urges. The parents may even subtly encourage these behaviors from their children without actually asking them to do anything. A parent might, for instance, grin like a Cheshire Cat as they describe their little darling’s exploits to others in the child's presence.

Of course, they cannot actually praise the behavior of the child without admitting that they think what the child is doing is a grand idea, so they have to deny that that they are subtly pushing the child in these directions. In fact, they will turn around and criticize the child for exhibiting the very behavior they are pushing the child to perform. This is the most common and typical type of double message seen in dysfunctional families. Damned if you do, damned if you don’t.

This general pattern of acting out is not limited to repressed ambitions and repressed hostility. A whole range of repressed feelings, urges, and even beliefs can be acted out by children. Let me give one more example.

Let’s say Mom was brought up in a severely and strictly religious family that preached that women must and should be totally subservient to their husbands. On the surface, Mom may claim to really believe that this is the way things ought to be, and join in with friends and fellow church members in loudly condemning more assertive women.

Underneath this almost smug sense of being satisfied with this allegedly morally superior way of  relating to their husbands, the women may actually be seething and chomping at the bit to decide for themselves how to behave, even if their husbands disapprove. In such a situation, they are actually jealous of the assertive women they criticize. They also covertly hate these other women, because the other women serve as a constant reminder to them that they are not really happy being on a leash. If they lived in a cave and didn’t get cable, as comedian Bill Maher used to say, they would not see that there were other options, so these hidden dissatisfactions might be easier to ignore. But alas, they do not.

Children are very perceptive and try to find ways to make Mom feel better. They look for ways to allow their mothers to vicariously live through them as they behave in a somewhat assertive way with the men in their lives. On the other hand, they cannot be too successful at being assertive in this manner, because that too would remind Mom of how unhappy she is when perhaps she does not have to be.

This bizarre situation can lead a child in this position to devise ways to walk this tightrope. Actually, there are a whole host of different strategies than can be employed to accomplish this seemingly impossible feat. For example, a daughter in this situation may marry a series of domineering and possessive men, put up with them for a while, and then go all ballistic on them in a wild and ultimately self-defeating form of rebellion that may adversely affect their own children. They then leave each men and go on to another one just like him.



Their mothers and other interested parties then get to tell them how insane they are, and also get to remain smug in the knowledge that they themselves would never act in such a manner. Being a "wildwoman" may even become a label by which other people tend to refer to them.

This is of course is just one example of ways in which children may develop a false self or persona. While the intrapsychic conflicts of the parents affect every other member of the family to a greater or lesser degree, one sibling out of many may become “it” while the others escape relatively unscathed.