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Wednesday, June 30, 2010

A Sucker Born Every Minute. Or Was That a Doctor?

A recently-published survey of almost 600 attending (academic) physicians and residents (trainees) showed that the recent increased emphasis on conflict of interest by the profession, as well as press reports about the horrendously dishonest marketing practices used by the Pharmaceutical Companies (PhARMA) in recent years, have apparently not changed the generally positive attitudes toward drug marketing activities held by the majority of physicians. 25% of the study sample even had no problems with accepting large gifts from industry representatives, according to an article in the June issue of Archives of Surgery.

Academic doctors may be a biased sample, since so many of them have financial ties to pharmaceutical companies or have pharmaceutical companies financing their research (which is necessary for them to do in order get tenure). However, in my experience, most other doctors have the same attitudes.

Some of the findings in this particular study were rather trivial. I personally do not think that giving free samples of new medications provided by pharmaceutical representatives to patients, or talking to drug reps about new medications (for which the industry has the most information available), necessarily turns physicians into corrupt robots, although surely these activities have that effect on some doctors.

However, some of the study findings were alarming. Most of the sample felt that grand rounds (academic presentations given in medical schools that are attended by a whole department) that are sponsored by pharmaceutical companies are instructive (80.5%) despite the fact that 68% felt that the talks were biased in favor of the sponsor's product. In my experience, these sponsored lectures used to me more academic, but in recent years they have degenerated into extended commercials for a company’s product.

It was also interesting that only 35.6% of the study sample admitted that accepting lunches or gifts influences their own prescribing, but 52.2% said that doing so influences colleagues' prescribing. In other words, many doctors think they are immune themselves, but that other are not. I have heard other numbers bandied about in talks that indicate that even a smaller percentage than this of doctors think they are influenced, while a greater percentage thinks that other doctors are. Even in this study, about three-quarters (72.7%) of the doctors surveyed believe company marketing does not influence their own prescribing at all!

A pro-PhARMA blog called Policy in Medicine, which interestingly posted and then deleted a brief comment I made about the dishonest marketing techniques that were described in detail in US Justice Department memos in cases against several drug manufacturers, had a very interesting spin on these results (http://www.policymed.com/2010/06/physician-across-specialties-value-their-relationships-with-industry.html). Instead of being concerned that doctors were being induced to prescribe drugs which might not always be in their patient’s interests, they were concerned that doctors might be cut off from a valuable source of information about new drugs.

They exclaimed, “These positive results demonstrate that relationships with industry, which ‘nearly all physicians maintain,’ are important and valued by doctors. The belief that such relationships need greater awareness because of their prevalence and potential for conflict of interest is accordingly misplaced, especially since numerous recommendations from individuals, organizations and companies to improve transparency and independent regulation already exist. While the authors [of the survey] believe that ‘the effectiveness of these policies is uncertain,’ their results clearly show that whatever potential risk there may be, the benefits of such relationships for physicians far outweigh them...

...Accordingly, in attempting to bring negative attention to such relationships, the authors claim that ‘there is widespread public concern that financial relationships between physicians and industry lead to conflicts of interest.’ Such a claim is unsubstantiated considering the authors acknowledge that “evidence of physician-industry marketing relationships resulting in patient harm is inconclusive.”

Inconclusive!! Tell that to the people who had heart attacks and strokes after being prescribed Avandia when cheaper and safer drugs were available (FDA epidemiologist David Graham’s study showed that patients taking Avandia had a 27% increased risk of stroke, 25% higher chance of developing heart failure and a 14% increased risk of death over patients taking the drug Actos) . Tell that to the patients with bipolar mania who were given Zyprexa instead of lithium and developed diabetes.

Another of Policies in Medicine’s conclusions: “The results of this study show precisely how important they [relationships with industry] are to physicians and their training.” Really? I would say that what their results really show is that an awful lot doctors are not aware of how much they are being misled and influenced by people whose only concern is profit and not patients.

Even the pro-PhARMA site did note in passing:

“Many participants found large gifts unacceptable and, like participants in previous surveys, believed that other physicians were more likely to be influenced by gifts and food from industry than they were.” And…

“Participants had overall positive attitudes toward marketing-related interactions with the pharmaceutical or device industries, with most agreeing that industry educational materials and industry funding of education are useful, although 68.0% perceived bias in sponsored lectures.” And…

“…physicians can readily access independent information about drugs through journal articles and studies.”

Of course, there was no mention on the site that the journal articles may also reek with drug company bias – a far more important marketing tactic than the pen and the pizza that pro-PhARMA doctors like to get indignant about (“To think that my prescribing could be bought so cheaply!”)

If these physicians had not noticed, the drug companies have not made too much of a stink about having to get rid of the “small gifts,” nor for that matter about the new and stronger rules regarding disclosure when academic psychiatrists are being paid bundles by drug companies for giving talks and writing articles in throw-away journals – journals that all doctors have mailed to them free of charge! The companies have readily agreed to gift bans because, while they are effective in inducing doctors to prescribe their drugs to some extent, this practice is actually the least important marketing tool they have. And hardly any doctors really pay that much attention to financial disclosures.

The pro-PhARMA site also stated, based on another published study, that prescribers “are able to effectively manage PR interactions such that their own prescribing is not adversely impacted.” As a result, the study offered a parallel conclusion that “providers from several health professions continue to believe that PR interactions improve patient care, and that they can adequately evaluate and filter information presented to them by PRs.”

Well, maybe if you only looked at the pen and the pizza? Maybe not even that.

Policy in Medicine’s final conclusions: “Clearly then, physician attitudes are in fact aligned with those of the public because patients are living longer and healthier lives, physicians are receiving better training and information, and medicine is continuing to advance. These results show that by working with industry, physicians are being viewed as part of the solution, and as such, physicians must make it known that collaboration is in the best interests of the public.”

Whether collaboration is important depends strongly on how the collaboration proceeds and how it is regulated. Interested readers can read more about dishonest marketing practices in my earlier posts Pfizer Fraudulent Marketing Techniques (March 17, 2010) and The Zyprexa Documents (March 22).

Saturday, June 26, 2010

Hitting Denial on the Head

In my post of June 11, How Can You Be Empathic With a Child Abuser? I mentioned the importance for an adult who was a victim of past abuse of finding a way to talk with the perpetrators about, or metacommunicate about, the family dynamics that led to the abuse . I also discussed the secret of getting past their defenses - empathy - but mentioned that empathy alone was not enough.

One of the biggest challenges in any such endeavor is staying cool while an abusive parent systematically denies ever having been abusive. Not only is this denial of the facts - or lying as I prefer to call it - infuriating, but once a person gets through one type of denial with the perpetrator, there are three other types of denial that will likely follow, one after the other.

Barrett and Trepper, in an article in the Family Therapy Networker (now the Psychotherapy Networker) in 1992, pointed out that families have multiple layers of denial, which often come out in the same order. As one breaks through each of these resistances, the next one pops up in its place.

The presence of denial is not a reason to avoid attempting to metacommunicate. The presence of multiple resistances represents multiple problems to be solved, not multiple reasons for giving up. Forewarned is forearmed. Knowing that these maneuvers may be forthcoming from perpetrators helps former or even current victims steel themselves in order to maintain an empathic stance throughout what may be a lengthy process.

Barrett and Trepper’s predictable stages of denial are as follows:

1. Denial of facts (“it never happened; you’re a liar!”), followed by:

2. Denial of awareness (“I was drunk,” or “I didn’t realize I was neglecting you; you should have told me”), followed by:

3. Denial of responsibility (“You were the one who was seductive,” or “If your mother didn’t deny me, I wouldn’t have to have turned to you.”) and finally:

4. Denial of impact (“It only happened a few times,” or “It was only fondling,” or “OK, so I beat you. Why do you always have to dwell on the past? You’re just too sensitive; get over it!”).

The exact words and strategies to use in order to counter these types of statements is different in every family. For many people, attempting to confront an abusive parental figure probably is a not wise thing to do without the guidance of a therapist who is well versed in this type of work. This is particularly true for a highly reactive family in which physical violence or vicious verbal attacks are a distinct possibility. A bad attempt at metacommunication can actually be far worse than no attempt at all.

Barrett and Trepper, in the same article, say that they “…believe that some part of every offender is appalled by his own deeds and desperately yearns for the kind of inner peace and satisfaction found in healthy relationships not based on power, manipulation, and secrecy.” As I discussed in my earlier post, I concur wholeheartedly, although many other therapists may disagree.

Wednesday, June 23, 2010

The Protection Racket

The recent case of Abby Sunderland, the 16 year old girl who famously tried to be the youngest person ever to sail solo around the world and whose boat became disabled in a severe storm, has become a virtual Rorschach test on parenting. Editorial columns, letters to the editor, and online debates question the sanity of the parents who let the girl try out such a clearly dangerous activity, and argue about whether or not they pushed her to do it for the money they would earn from a reality show (although Abby’s brother Zac had already achieved the feat and the family apparently got very little money from that).

Some of the debate also centered around the question of who should have to pay for the cost of her rescue, although I do not recall that question being raised quite as much when several mountain climbers had to be rescued off of snowstorm-infested Mt. Hood after attempting to climb it in the wintertime.

A legitimate question about how much risk parents should allow their teenagers to take, and how protective of their children parents should be has been all but drowned out by extreme emotion.

Some people have applauded the Sunderlands for “brave parenting” and for fostering maturity in their offspring. Clearly Abby was quite mature and knew what she was doing. A lot of adult sailors would have trouble keeping their boat upright in 20 to 25 foot waves after the mass was snapped off, or have the presence of mind to quickly activate manually operated emergency radio beacons. Still, should that sort of risk-taking be encouraged in anyone, let alone a teenager?

On the other side are parents who think it’s too dangerous to let their children play outside on their suburban front lawns, walk two blocks to school, or surf the internet unattended for fear that the children will be whisked away by sexual predators.

Now of course children do get abducted. According to the National Center for Statistics and Analysis, there are 3,000 to 5,000 stranger abductions per year, which are mostly cases of sexual assault rather than kidnapping. Of course, there are 40 million kids in this country, making the odds of such an abduction around 347,000 to 1! Compare that to the approximately 3000 children between the ages of 2 and 14 who die in car crashes every year, or to the estimated 1,530 children who were killed by their adult caretakers in 2006, or to the nine hundred and six thousand child abuse convictions in 2003 alone.

Makes you wonder about how some folks assess risk.

Where’s the middle ground on keeping children safe? It seems to have disappeared.

“Protecting” children from themselves is nowadays often taken to extremes in which the parents actually cause their children to be less safe because the kids never learn how to fend for themselves or to tolerate adversity. A recent letter to the editor in my city’s newspaper opined that parents who do not randomly drug test their teens, regardless of whether or not there is any evidence that the children may have used drugs, have their heads in the sand. I would be more concerned that those children who had never used drugs would interpret such action by the parent as indicative of the parent’s expectation that they are going to use drugs, as well as the parent's expectation that they are incapable of using good judgment.

Children frequently misinterpret such parental overconcern as a sick need on the part of the parent to be some sort of rescuer - whether the children need rescuing or not. Such kids then often act as if they continually need to be saved from themselves - in order oblige the parent’s apparent need to do just that.

Sunday, June 20, 2010

If You Comply When Everyone Around You Wants You to Be Oppositional, Which Have You Done?

In my post of April 17, 2010, The Language of Love, I discussed the idea from my book, Deciphering Motivation in Psychotherapy, that there are hidden aspects of language created by its inherent ambiguity. Any sentence in any language can have at least two different meanings.

Linguists refer to the way language is used to affect the behavior of other people as the pragmatics of language. In today's post I will give three examples of how language also reflects a basic split in human nature between what is called the persona or false self and what really transpires in the human mind.

We all keep many of our thoughts to ourselves in various contexts, because we must always negotiate the social order of which we are a part. In each situation, we must all decide: Do we say and do things because we really want to say and do those things? Or do we say and do what the groups to which we belong want, need, and/or expect us to do or say?

The false self is that image we project to the people around us, which may or may not be an honest reflection of what we really feel and believe. For example, we may be furious with someone yet act with nothing but sweetness and light around them - because we fear how they may react if we expressed our anger.

In no other situation is this phenomenon more pronounced that in our relationships with our families of origin. We are all biological inclined, although not predestined, to act out roles or scripts which help our families to function. However, sometimes, for reasons I will not elaborate on here, the family becomes confused or ambivalent about what they expect from us, putting us in a bit of a bind.

A simple yet deadly example of this occurred in the case of a woman of East Indian descent who was born and grew up in the US shortly after her parents emigrated here. As she got older, because of her English language skills and familiarity with American culture, her parents expected her to be the front person whenever they had to deal with the larger culture. She became quite Americanized, but in reality had one foot in each culture. She made the mistake of falling in love with an Anglo American. Her parents expected her to marry the man that they had, by their tradition of arranged marriages, picked out for her. She ended up committing suicide because she saw no way out of this dilemma.

If indeed we are willing to sacrifice our own personal inclinations in order to play our part in our family’s functioning, how do we explain all of the people who seem to be acting in direct opposition to what the family says they want? Could it be that people are oppositional only because that’s what they think their family needs them to be?
I say yes. With many patients who complain about other family members’ behavior, I find that there are some heavy duty mixed signals going on. They may, for example, leave money around knowing that their children will steal it.

Some parents make demands of their children over and over but never stop their children from disobeying. In fact, they may smile as they tell stories about how their children (and by children I also mean adult offspring) are so terrible. They may seem to have a compulsive need to keep repeating the same demands of them over and over, as if their children did not hear them the first 500 times they made the demands.

That brings us to the first common example of ambiguous language: the oppositional teenager who yells back, “Why do I have to listen to this?!?” when repeatedly lectured about what to do. Since kids like this rarely obey the instructions, a seemingly more appropriate response would be, “I heard you the first time, and I’m not going to do that.” After all, most people would reason, the kid does not have to listen to the lectures – all he or she would have to do to stop the demands would be to do what he or she was told to do!

Well, maybe and maybe not. Teens who go ahead and finally do what they are told are often then told that they are not doing whatever they were told correctly. They feel that no matter what they do, they will never be able to please their parents. I believe the correct translation of “Why do I have to listen to this?” in such a situation is actually, “Why do you have this compulsive need to keep telling me over and over again what to do? I will be oppositional so you can continue to indulge yourself!”

A somewhat similar statement came from a rather sexually promiscuous woman who told me, in the context of describing this behavior, “I am always afraid of disappointing my father.” The average person who heard this might come to the conclusion that this woman was deluding herself. Surely the father must be disappointed in her behavior, so how can she say that she is afraid of disappointing him?

Well, once again, maybe not. If it is true that the woman is not deluding herself, then the correct understanding of her statement in context would have to be, “My father would be disappointed if I were not promiscuous." Maybe the father was secretly angry at women who withheld sex, while usually pretending to adhere to his family’s belief that sexually open women are all sluts.

My third and last example came from a mother who screamed at her adult daughter with a disapproving look and tone of voice, “I just can’t believe you talk to your boss that way!” I believed that the look and tone of voice actually reflected the mother’s false self, not her real feelings. In fact, I saw evidence that her mother actually admired the daughter’s assertiveness! If we look at just her words apart from tone and body language, we can see that her statement actually contains no value judgment at all. It merely expresses surprise about the daughter’s behavior.

The tone and body language accompanying a statement are often reflective of a false self, while the words themselves can reveal clues to a person’s true feelings.

Thursday, June 17, 2010

Thirteen

Psychologically disturbed and mentally ill characters are a staple of Hollywood dramas. While screenwriters can occasionally be quite perceptive about human psychology and family functioning, much of the time their creations do not correspond well with the actual people that come to therapists and psychiatrists for treatment. Sometimes screenwriters are in fact utterly clueless – and in nowhere is this problem more obvious than in the depiction of people who suffer with borderline personality disorder. Glenn Close’s character in Fatal Attraction was a bit of a caricature.

Every so often, however, a movie comes out that absolutely nails a psychological phenomenon. Such is the case with the movie Thirteen, which should be subtitled, How to Turn Your Teenager into a Borderline Without Even Being Abusive.




Many critics saw this as a movie about the dangers that young teens face from peer pressure, rather than as a portrait of family dysfunction. Part of the reason these critics miss the point of this movie is that, ever since certain therapists came up with unscientific and at times observation-free theories of the role of parenting in the genesis of schizophrenia and autism, it seems everyone is afraid to examine the role of family behavior in the genesis of any other psychological disorder. This is political correctness gone amok.

The protagonist of Thirteen, Tracy, starts out with very nice peers and fellow students before she begins to gravitate to the “corrupting” peer Evie. Even though Evie is attractive to the boys at school and thus her behavior might represent temptation for a teenage girl, her other more dangerous behavior would be a signal to less fragile teens to stay as far away as possible. To which peer group a teen is attracted is no accident of fate. Peer pressure is a red herring in the movie because these peers seek one another out.

The most fascinating thing about this movie was that it was co-written by then 15 year old Nikki Reed, and it was reportedly semi-autobiographical. According to Wikipedia, Reed’s parents divorced when she was two, and she grew up with her mother. She describes herself as having been "shy and a bookworm" until the the age of 12, when she became rebellious and emotionally volatile. The relationship between Reed and her mother became strained. At the age of 14, Reed was emancipated; she then moved out and began living on her own.

Nikki Reed and co-writer/director Catherine Hardwicke reportedly finished the script for Thirteen in just six days. Ms. Reed must have had rare insight into her family, especially for someone so young, because the film is just packed with true-to-life details about what growing up in a “borderline” family is like. In the movie, she also acts the role of Evie, although in reality her story was far closer to the story of Tracy.

Tracy’s mother in the movie, Melanie, grew up without a mother in her teenage years, is divorced, and is a recovering alcoholic. She lets her recovering cocaine-addict ex-boyfriend, Brady, back in her life, to which Tracy reacts with utter dismay and a torrent of criticism towards Mel. “Why are you doing this to yourself?!” she scolds her mother in a role reversal. Tracy is also perturbed because Mel allows her friends and customers to take advantage of her financially. Tracy’s sense of helplessness over her mother’s behavior seems to be what triggers her self-injurious behavior, cutting.

At one point after seeing Mel with Brady, she flashes back to Brady becoming sick from drugs. She then goes to the bathroom and starts to cut herself. It appears that she knows exactly where the implements of self cutting are and exactly what to do. The strong implication is that she has done this before – and most likely well before she ever met Evie.

Tracy’s only power with her mother is her ability to induce guilt in a mother who is completely overwhelmed by the responsibilities of parenthood. Mel’s guilt probably stems from issues in Mel’s own family of origin. This power is frightening for Tracy. When coupled with her mother’s covert admiration for Tracy’s freedom, it induces Tracy to begin to follow in her mother's self-destructive footsteps and to exceed them. For example, the mother knows that Tracy has started to steal, but says nothing and looks somewhat approvingly at her stolen clothes. When Tracy finally confronts her mother’s denial, Mel responds that she just did not think it "went that far."

As Tracy begins to act out more and more and to learn more self-destructive behavior from her new friend Evie, Mel tries to set limits. However, Mel always seems to back down in the face of Tracy’s guilt trips, sarcasm, and feigned outrage. At one point Mel completely loses her cool in the face of Tracy’s spoiling behavior and goes into her own rage, starting to destroy her own kitchen until Brady comes in and stops her. Of course, Brady becomes overwhelmed and moves away from Mel.

Mel tries to call in Tracy’s biological father to help control her. The father has apparently been a frequent no-show on his days to be with Tracy because he is always busy with his job; Tracy is bitterly disappointed when this happens. After Mel calls him, he comes to see if he can solve Tracy’s problem and demands to know what is going on “in a nutshell” while continually being interrupted by cell phone calls from work. Tracy’s brother throws his arms up in frustration when the father begs him to tell him what is going on. Later Mel speaks of letting the father take over Tracy full time - she says “I’m terrible” under her breath - but Tracy concludes that her mother does not really want her.

Evie comes from an abusive borderline environment. It’s hard to know exactly what is true about her and was is not because of her incessant lies, but Evie says her mother was a crack whore. Her uncle sexually abused her and pushed her into a fire – she has the burn marks and a newspaper article to prove that. Her care has been taken over by Brooke, a cousin, who lets her drink beer, tells her she is not allowed to go certain places but never seems to really care what Evie is doing, and disappears for days at a time.

Evie secretly yearns to be adopted by Tracy's better-by-comparison family. For reasons I will not mention here (so as not to spoil the ending for people who have not yet seen the movie), she induces her denial-filled guardian to make a mistake similar to the one made by a lot of movie critics: the guardian blames Evie's reckless behavior on peer pressure - from Tracy!

There are a lot more details in the movie – and there is not one scene that rings false. Nikki Reed seems to know more about the environment that spawns borderline personality disorder than do most therapists and psychiatrists.

Monday, June 14, 2010

Lexapro and Prestiq: Nothing New Under the Sun

Remember a couple years ago when television was blanketed with ads for Nexium, the purple pill that represented the next "big step" in the treatment of gastric reflux esophagitis? Was this medicine something new? Well, sort of. To understand what the manufacturer did, first you have to know a little simple chemistry.

Molecules, as most of know, are made of atoms of various elements in a fixed ratio, like H20 is two hydrogen atoms and one oxygen atom combined to make water. If a molecule is large enough, two molecules with exactly the same chemical formula and structure can have slightly different geometry. The two molecules can be mirror images of one another, creating what are called enantiomers. The R-enantiomer is the right handed version and the L-enantiomer is the left handed version.

In particular, some drugs can have both L and R versions, but only one of the two versions may be active in the body, while the other is either completely inert (the usual case) or, in a few instances, creates different side effects. A mixture of the L and R versions is called a racemic mixture.The reflux drug prilosec is such a racemic misture. One enantiomer is active and the other is inert.

When prilosec, a highly profitable blockbuster drug, was about to go generic, the manuafacturer did something to preserve its profits. It created Nexium, which was not a racemic mixture but the single active enantiomer. Of course, the inactive enantiomer in Prilosec is inert, so in order to ingest an equivalent amount of "Nexium," all you have to do is take double the dose of prilosec. There would be no difference at all. And there is no evidence that Nexium is any more effective or has fewer side effects than Prilosec!

Lexapro, one of only three anti-depressants that have not already gone generic, is the R-enantiomer of Celexa (Citalopram) and is a lot more expensive than generic Citalopram, but in all other respects is nearly identical. Some people claim to have more side effects on the original drug, but this is debatable. They are equally effective, so why pay more?

Another trick the pharmaceutical companies use to extend sales of expensive, brand-named drugs when they are about to go off patent is to release what is called the active metabolite of the original drug as a new drug. For example, when the old antidepressant Elavil (amitriptylene) was broken down in the body, the first new molecule created was nortriptylene (Pamelor). Nortriptylene was the active drug for depression, not Elavil.

Now, in that case Pamelor was an improvement because the parent drug, which was not psychiatrically active, did have a lot of side effects that its metabolite did not. Elavil also had to be prescribed in much higher doses, which made its overdose potential more of problem.

When the antidepressant Effexor (venlafaxine) was about to go off patent, the drug company came up with Pristiq, which is desvenlafaxine, Effexor's active metabolite. The effectiveness of the two drugs is once again absolutely the same if the proper dosage is prescribed, and in this case, side effect differences are minimal. Pristiq's only advantage is that it has a narrower effective dosage range, so the doctor does not have to slowly increase the dose of the medication to see what the minimal effective dose will be in a given patient.

Still, unless money is no object, a patient might want to go with the cheaper generic alternative. I have no sympathy for insurance companies, but their interests are finally beginning to diverge from those of big PhARMA in a good way. They are starting to push for use of the generic alternatives for their subscribers in order to save money.

Friday, June 11, 2010

How Can You Be Empathic with a Child Abuser?

With my non-pychotic adult patients who exhibit chronic self-destructive or self-defeating behavior patterns, chronic anxiety and depression, and/or overt family discord, I eventually get to the point in psychotherapy where I recommend that they talk to their parents (or other primary caretakers) about their family dynamics. I tell them we will work on getting past their parents' rather formidable defenses, and finding a way to discuss their long mutual history of dysfunctional interactions. We will figure out a strategy for stopping ongoing, repetitive, and troublesome interpersonal exchanges, which will hopefully lead to reconciliation.

Even if the patients are finally convinced that it might be very helpful for them to do this, the first response I get is usually some variation of, "That's impossible." The patients then go on to describe how their families are the most difficult human beings on the planet, and how there is just no way their parents will ever be approachable like that, let alone alter the way they interact with the patient.

They go on to say that if I knew these people, then I would know this would be a fool's errand. Besides, they've already tried a variety of different strategies to talk to them, and got nowhere. Certainly, I could not possibly have ever seen a worse family.

Actually, after 30 years of doing this sort of work, I probably have seen families that are much worse. Every time I think I have seen family members mistreat one another in every conceivable way, I am in for a shock. Soap operas ain't got nothing on real families.

Nowhere is convincing patients of the need to do what I recommend more difficult than for those cases in which one or both parents had been physically or sexually abusive to my patients when they were children, when other important family members did nothing to protect the abused child, and when the parents refuse to admit than anything untoward ever even happened. Worse yet are the parents who blame the patient for the abuse. One patient, right after a particularly reprehensible act by her father, was given a copy of the book The Bad Seed by her mother. The novel is about a little girl who was born bad.

The task of reconciling seems even more absurd in such cases when I tell the patient that he or she has probably not yet employed the basic secret of being able to get past parental defenses and calmly discuss family dynamics (a process called metacommunication). That secret is showing the parents empathy. Employing attacks and recriminations only leads to the parents exhibiting even more or their defenses, employing fight/flight/freeze reactions, or resorting to nasty verbal attacks and even family violence. (The exact way empathy is used in metacommunication must be different in the case of every family, however. Generic assertiveness skills often do not work. Interventions must be tailored to the family's sensitivities).

Empathy for a child abuser? For a child molester? I have got to be kidding, right? How can you be empathic with someone who has done something so heinous?

First, even parents who do horrible things almost always have redeeming qualities as well. No one is all bad (thinking otherwise is splitting, subject of an earlier post). They were not abusive twenty-four seven. Sometimes they were nice. Many people who were abused as children do not like to think about the times their parents were loving - it is just too confusing and therefore upsetting. It is much easier to focus on the hateful side.

Some take the opposite track and try to make excuses for the parents. All of them really have very mixed feelings about the parents and secretly wish for a healthy connection. Also, they fear that since their parents are monsters and they came from them, then they might be monsters too. Some folks with an abusive background are afraid to have children for fear that they, too, will be abusive.

Second, most people get empathy mixed up with sympathy. There is a huge difference. Abusive parents are not very sympathetic characters, to say the least. Empathy, however, means trying to understand what factors led the offender to do what he or she did without condoning what was done. Sympathy is saying that what happened was sort of OK. Saying that what they did was somehow excusable is, in fact, not empathic at all.

Why? Because abusers know, despite all their denial and verbal nastiness, that what they did was horrible. They are not stupid, and they know wrong from right. Their biggest secret fear is that their children hate them for it, and that they deserve not only the hatred that they receive but eternal damnation. This is why they use denial: not to escape responsibililty, since they and their children know very well what happened, but to make their children give them the hatred they think they deserve! If an abused individual says that what the parents did was all right, the parents know immediately that their child is lying. Lying can never be empathic, because it is phony.

In general, I use genograms, which are sort of the patient's emotional/historical family tree, to try to help patients put their parents' behavior in a more understandable context, so that the patient's justified anger becomes more manageable. Understanding the parents' past experience makes them seem less like monsters.

Also, it is important for patients to understand that getting past their parents' denial is a multi-stage process. There are usually four different types of denial that are employed, one after the other, as each one is confronted and then diffused - but that's a matter for a future post.

Tuesday, June 8, 2010

Parental Alienation Disorder

In my May 20th post, Babies and Bathwater, I remarked how I am constantly amazed by how people can take obviously extreme positions and then argue vehemently for them. I came across another example of this in a column and a series of letters to the editor in Clinical Psychiatric News about something called Parental Alienation Syndrome or even Parental Alienation Disorder (PAD). The original column was by Dr. Paul J. Fink, M.D.

A group called Fathers & Families has been organizing a letter-writing campaign urging the APA to list PAD as a disorder in the DSM (http://www.fathersandfamilies.org/?page_id=5372). They define PAD as "a disorder that arises primarily in the context of divorce/separation and/or child-custody disputes. Its primary manifestation is the child’s campaign of denigration against a parent, a campaign that has no justification. It results from the combination of a programming (brainwashing) of a parent’s indoctrinations and the child’s own contributions to the vilification of the targeted parent. Parental Alienation is also sometimes referred to as 'Parental Alienation Disorder' or 'Parental Alienation Syndrome.'”

In other words, this group wants the APA to recognize that sometimes, in a nasty divorce, one parent (usually the custodial parent) turns the child against the other parent so that the second parent can not have a normal relationship with his or her child. The group recognizes that PAD may be more of what is referred to as "relational disorder" in the DSM rather than a true psychiatric illness. However, they believe that including it in the DSM will "...increase PA’s recognition and legitimacy in the eyes of family court judges, mediators, custody evaluators, family law attorneys, and the legal and mental health community in general. Adding PAS would also "spur insurance coverage, stimulate more systematic research, lend credence to a charge of parental alienation in court, and raise the odds that children would get timely treatment.”

Since the custodial parent is even now still more frequently the mother after a divorce, Fathers & Families was organized originally to advocate for the rights of fathers, and to protest the way fathers are often portrayed negatively in the media.

In nasty divorces, one tactic that is sometimes employed - and quite effectively - to keep the father out of the child's life is to falsely accuse the father of having sexually or physically abused the child. Children under adult influence can in fact easily be manipulated into making accusations that are not true. (For reasons I discuss in my book, in the infrequent incidents when adults make false accusations of having been abused as children, that is an entirely different story. I know this remark might generate some flack from the False Memory Syndrome Foundation types, but I will not get involved in a debate about it on this post).

Such false accusations are clearly reprehensible. However, a big problem is created. How do we know that the accusations are indeed false? Perhaps the reason the mother wishes to keep the child away from the father in the first place is that he is actually abusive. The abusive father might then turn around and falsely accuse the mother of making up allegations of abuse in order to cause PAD.

Dr. Fink deservedly got into some hot water for saying in a column advocating the position that PAD is junk science that those advocating inclusion of PAD in the DSM "don't like to be interfered with when they are sexually abusing their children." I am amazed that the editor of the newpaper allowed that in. Dr. Fink apologized in response to the critical letters to the editor that followed the publication of his column.

His statement is clearly one of those extreme positions I decry, although hopefully he was sincere when he retracted it. How can anyone think that parents never turn their children against an ex, or that any father who thinks this is happening is a pedophile?

Thankfully, the Fathers & Families group does not, at least at first glance, seem to go to the opposite extreme. They say on their website, "as we’ve often noted, simply because false claims of Parental Alienation can and are made doesn’t mean that Parental Alienation doesn’t exist or isn’t a problem."

Clearly, all claims of abuse and PAD (or just parental alienation if you object to its being included in the DSM), should be investigated on their own merit with out a pre-determination of who is telling the truth and who is lying. In nasty divorces, all bets are off.

Saturday, June 5, 2010

The Latest Child Abuse Statistics

The fourth National Incidence Study of Child Abuse and Neglect (NIS-4) was released in January of this year. This is only the fourth such report, which were mandated by the US Congress 36 years ago. These reports are based primarily on the number of actual cases in which a child was removed from the home and placed in foster care.

Of course, the actual incidence of childhood abuse is really unknown. This is because a lot of cases go unreported, and because the definition of child abuse keeps changing, but also because there are advocacy groups on both sides of the issue with motives for exaggerating or minimizing the actual incidence as the case may be. I discuss the whole issue of the extent of child abuse in the US in my upcoming book.

According to the Psychiatric News of 4/2/10, the number of children who experienced any kind of abuse dropped from 743,200 in 1993 to 553,000 in 2005-2006. An impressive drop, but still a staggering number of cases in just one year.

Interestingly, however, the number of children removed from families and placed in foster care continues to rise. The difference seems to be due to a doubling of the rate of children who were subjected to something called emotional neglect. The number of kids subjected to that in '05-'06 was 1,173,800 - an amazing number. In 1993, 584,000 such cases were reported. Some of this increase may have been due to more widespread reporting of this phenomenon by teachers and law enforcement, but quite possibly there is more of it taking place.

Emotional neglect is not defined precisely in the report, but the study said it included such things as permitting a child to abuse drugs or alcohol, permitting "maladaptive" behavior such as chronic truancy, and refusing or delaying needed psychological care. The NIS-3 also included in the definition children who witnessed domestic violence. This latter focus may be somewhat new, which is an odd thing to say because of the well-known toxic effects on children of watching their parents beat the hell out of each other.

If the incidence of allowing children free run so that they are undisciplined and act out is really increasing, this would be strong evidence for parenting columnist John Rosemond's assertion that today's parents are often far more ineffective in setting limits with their children than they were even a couple of decades ago.

In yesterday's column, he defined this problem as a failure in parental leadership. Parents nowadays try to be behaviorists with rewards and punishments, but human children are far more resistant to changing their behavior in response to this "behavior modification" strategy than lab rats. He quoted an older friend of his who, when asked how his parents caused him to be obedient to their wishes, replied, "They didn't use any methods at all. They simply expected, and their expectations were clear."

Wednesday, June 2, 2010

Step up to the Plate

Are one or more of your kids completely out of control? When you spend time with your parents or even talk to them on the phone, do you feel like you've just spent hours listening to a bunch of people simultaneously scratching their fingernails on a chalkboard? Do you find yourself hurting the ones you love, or letting them hurt you? Do you feel that your family members are better off without you? Were you a victim of childhood abuse? Do you constantly subvert your own chances for success in love and work? Are you chronically anxious and depressed?

These types of issues are often, if not almost always, indicative of family dysfunction. That's OK. You do not have to beat yourself up about it. It's not all your fault, although you do have something to do with it. All families have issues and conflicts, although some are far worse than others. Hating yourself and/or feeling guilty about everything not only makes you miserable, it makes the rest of your family miserable as well, and can cause problematic, repetitive family behavior patterns to be passed down from one generation to another. This intergenerational transmission of family behavior problems has been shown in good studies (studies that organized psychiatry tends to ignore). It is not genetic either, despite what you may be hearing.

It is never too late to stop the intergenerational transmission of dysfunctional family patterns. That's the good news: the process can be stopped. However, you can not buy your way out of it with pharmaceuticals, although medication can ease distress. When the drug companies win, you lose.

Despite the discomfort it will invariably cause you, step up to the plate and repair the relationship with your parents and save your children and their children. Otherwise, you and your children may be caught in an endless loop. Good psychotherapy is available. However, going to therapists who blame your problems on your having regressed to childhood, or who tell you that your thoughts are all irrational and unfounded or that you are no more complicated than a rat in a maze responding to food pellets and electric shock, will not solve the problem of which I speak.

Find a therapist who know about genograms and /or mental schemas. Find one who can help you discover the nature of the repetitive interpersonal behavior patterns you engage in, and what purpose they serve. Such therapists can be difficult to locate, but it is worth the effort.

And stick with it! When you talk about the relationships that make you depressed and anxious, there is no way to avoid feeling more depressed and more anxious. I wish I knew a way around that, but I do not. I do know that most of you can take it. Although therapists should be empathic and non-judgmental, a therapist who treats you with kid gloves is not helping you. After all, if a supposed expert thinks you can't handle the truth, it is easy to believe that you are weaker than you really are.