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Friday, December 24, 2010

Leave Me Alone, I'm Lonely


When I discussed the concept of distancing in my July 6 post, Distancing: Early Warning, I described parents who distance their adult children thusly:  The parents act in an obnoxious manner that makes their adult children wish to avoid them. However, the fact that the parents are indeed pushing their children away is often somewhat obscurred by the fact that the parents keep demanding contact with their progeny.  The kicker in all this is that the  parents even do that in such a way that it has the opposite effect.  Still, the adult children frequently come back over and over again for more abuse.

I also pointed out that in these situations the parents may secretly believe that their children are better off without them. Hence, they engage in distancing to protect the children from themselves.

I would like to provide readers with some real examples.   

However, if I used examples from my practice, other therapists who do not like my family systems conceptualization (and there are many who do not) might accuse me of inducing my patients to make up this stuff just to please me.  These therapists do not believe this sort of odd behavior ever really happens.  So instead, I will use examples that I have been collecting from several different newspaper advice columns.  The columns are written by Jeanne Phillips (Dear Abby), Carolyn Hax, Amy Dickenson (Ask Amy), Harriette Cole, and the team of Marcy Sugar & Kathy Mitchell (Annie's Mailbox). 

Dear Abby
Dear Abby
         
Tell Me About It by Carolyn Hax, Advice Columnist

Ask Amy
Amy Dickenson
Harriette Cole

Now of course the writers of advice to the lovelorn columns are not trained therapists, and their suggestions to the readers who send in problems vary widely from the very psychologically sophisticated (Carolyn Hax) to the often naive, all too obvious, and glib (Annie's Mailbox).  

Nonetheless, in order to be successful at writing such a column, all of them have to be adept at writing about issues that resonate widely with readers.  They have to pick out a few letters that pique their readers' interest from the hundreds that they typically receive every day.  And it is not just females who read the advice columns, as was the case back when they first started.  (In England, advice columnists were once called "agony aunts" because they dealt with female letter writers who were always agonizing about something). 

Academic psychiatrists and psychologists tend to look down their noses at the popular press, and are often dismissive of advice columnists as well as op-ed writers who author columns on psychological issues -  as if non-professionals cannot make valid observations or have informed opinions.  That just shows how short-sighted the academics can be.  What they see in their offices and read in journals is frankly a highly skewed view of human nature.  They ignore the popular press at their peril.  And they need to get out more.

The problem of what I call distancing parents comes up quite frequently in the letters advice columnists choose to publish; what follows are a whole bunch of examples culled from recent columns.  (Of course, there are also a whole litter of letters by parents denouncing the dastardly dreadful dirty deeds of their ungrateful a-dult offspring, which not only allows me to alliterate but gives me material for another post later on.  Distancing is often a two way street).

According to one writer, her parents insisted on monopolizing most of her and her husband's social time.  When the couple moved out of state, hoping to solve this problem, her parents literally bought a house a couple of blocks away from theirs in the new state, and  moved into it.

A father, after divorcing the writer's mother when the writer was small, would rarely show up to spend time with his children when he had promised to.  These no-shows had always been a crushing disappointment for the kids.   Nonetheless, after the kids grew up, he constantly complained about how they refused to visit him.

The mother of one letter writer always cried to her about how awful she, the mother, was being mistreated by the writer's husband. From the writer's perspective, however, it was actually the mother who was consistently verbally abusive to the husband.

Whenever another letter writer disagreed with her father, he would reply, "Maybe I'll just kill myself."

When a writer's father became chronically ill, her mother constantly asked her to come over and help take care of him.  If she could not make it for whatever reason, the mother would launch into a long teary rant about how she, the mother, never got to go anywhere.  No matter how much the writer helped, Mom would constantly describe her as the "unhelpful sibling" when discussing the situation with the writer's sister.

Another writer had been physically and sexually abused by her father when she was a child.  After he died when the writer was an adult, her mother would go on and on endlessly about what a saint he had been.

A mother constantly blamed her daughter for the mother's divorce from the writer's father, although the mother would gush to complete strangers about what a wonderful daughter she had.

One mother was a real Cassandra; everything she talked about was gloom and doom about the future.  However, if her adult daughter was not all sunshiny about everything, the mother would berate her.

Another writer's parents always gave expensive gifts and money to the writer's older siblings, but never gave her anything.

When a writer and her husband generously took in her elderly and apparently agorophobic mother-in-law, Mom expected them to stay in the house with her 24/7 and would never want to go out herself. She also made huge messes in the house and constantly henpecked the writer's husband about what he was and was not doing.

One writer's mother repeatedly lied and gossiped to the other siblings about each of her adult childen behind their backs.

A writer complained that her mother had always treated her like crap, but doted on the writer's daughter.

A mother who was overprotective of her children when they were kids still expected a writer to check in with her every single night.

Another parent constantly embarassed her daughter in front of the daughter's friends; if the daughter did not do everything the mother told her to do, the mother would curse at her and call her names.

The parents of another writer consistently favored one of the writer's daughters over the other grandchild in a highly ostentatious way.

Finally, when one writer was literally dying of cancer, her mother made plans with a single friend to find a way for the friend to marry the writer's husband after she died.

That last one may seem over the top, but believe me, I've heard far more bizarre examples from my patients.   The parents described in these posts were pikers in comparison. It never ceases to amaze me how creative people can become in devising ways to annoy other family members.  Every time I think I have heard it all, boy am I ever in for a surprise.

Monday, December 20, 2010

Epidemic of Mania, Pharmaceutical Company Type (Bipolar Disorder P.C.) Claims Seventh Victim

Just as I thought I had heard the last about drug company mania mania, yet another example pops up.  Posts on this subject are starting to become a regular feature on this blog.  For the seventh time, the Justice Department has fined a pharmaceutical company for off-labeling marketing one of their drugs for a psychiatric indication for which there is no data, and once again the psychiatric indication is mania.  I hope these posts have not become monotonous.

This time the company is Elan pharmaceuticals and the drug - seemingly always an anticonvulsant or atypical antipsychotic - is the anti-seizure medication Zonegran.


According to the justice department press release at http://www.justice.gov/opa/pr/2010/December/10-civ-1444.html,  "Elan promoted the sale of Zonegran for a wide variety of improper off-label uses including mood stabilization for mania and bipolar disorder, migraine headaches, chronic daily headaches, eating disorders, obesity/weight loss and seizures in children under the age of 16.

Elan’s off-label marketing efforts targeted non-epilepsy prescribers and the company paid illegal kickbacks to physicians in an effort to persuade them to prescribe Zonegran for these off-label uses. Under the terms of the plea agreement, Elan has agreed to pay a criminal fine of $97,050,266 and plead to a misdemeanor violation of the Food Drug and Cosmetic Act. EPI will also forfeit $3.6 million in assets.

In addition, Elan has agreed to pay $102,890,517 to resolve civil allegations under the False Claims Act and related state statutes that the company illegally promoted Zonegran and caused false claims to be submitted to government health care programs for a variety of uses that were not medically accepted indications and therefore not covered by those programs."




The company was not accused of trying to expand their market by expanding the definition of bipolar disorder the way Eli Lilly did with their marketing for Zyprexa (see my March 22 post, The Zyprexa Documents).   However, would anyone be surprised if they had done this as well?  Any moody patient becomes fair game for a bipolar diagnosis.

Typically, the company "targeted non-epilepsy prescribers."  Translation: primary care doctors and perhaps psychiatrists. Apparently they are fairly easy targets to manipulate.

Friday, December 17, 2010

Child Abuse Politics

The United States Government's Department of Health and Human Services just issued a report stating that 1740 children in the US died at the hands of their primary caretakers in 2008 due to abuse or neglect  (http://www.commercialappeal.com/news/2010/dec/14/tennessee-ranked-fourth-child-abuse-deaths/). 

Elizabeth Loftus and the False Memory Syndrome Foundation promptly issued a joint press release stating that the childrens' memories of having been murdered had been falsely implanted by unscrupulous therapists.



Meanwhile, wildly indignant child abuse advocates accused the government of a serious undercount, and pegged the actual number of cases at closer to 300,000,000.

Tuesday, December 14, 2010

Tangled Emotions



In a very funny sequence in the delightful new Disney animated fairy tale, Tangled, Rapunzel steps down from the tower that the woman whom she thinks is her mother has insisted she stay cooped up in all her life. She goes outside and touches the ground for the very first time - without that woman's knowledge.

She immediately experiences severe mood swings as she goes back and forth from the heights of ecstasy to the depths of despair over and over again in a very short time. One minute she is marveling at the feel of grass as she runs through. The next minute she is crying and wailing, "Oh, I'm a terrible daughter!" Soon thereafter she beams as she thrills in splashing through her first pool of water. Shortly after that she anxiously frets that she is hurting the woman who raised her and whom she loves.



The Harvard Guru of Drugging Children, Joseph Biederman, would probably diagnose her as bipolar.  The male character who entices Rapunzel to come down out of the tower, however, is a much better diagnostician.  He observes that she seems to be at war with herself.

Ah yes, neurosis.  That old Freudian psychoanalytic term that signifies a conflict going on within a person (intrapsychic conflict) that allegedly creates the severe anxiety and self-defeating behavior seen in patients who come for psychotherapy .  Different psychoanalytic, existential, and humanistic psychotherapy theoreticians (that is, those from certain schools of thought within the field) disagree over precisely what it is that "neurotic" people are most often conflicted, but they all stand by the concept.  

Freud thought the conflict was between our internalized values and our biological urges - most frequently aggression and libido (psychic and emotional energy associated with drives)

Psychoanalyst Heinz Kohut thought it was over our needs to be validated, depend on others, and have a place to fit in within a family that may provide us with none of those things. 

Experiential therapists such as Carl Rogers and Fritz Perls thought it was over what our social system wants us to do and our need to self-actualize (achieve one's full potential through creativity, independence, spontaneity, and a grasp of the real world)

Erik Erikson saw it as a struggle to negotiate different developmental stages over our lifetime, such as the struggle between the forces of identity and role confusion during adolescence or the struggle between the forces of integrity and despair in the elderly. 

Existential therapists think it concerns our need to find meaning and connection in an absurd universe in which our own death looms. 

Family Systems pioneer Murray Bowen thought it was between the forces of togetherness and the forces of individuality.

Almost all of the above concerns, one might note, center around a battle between doing what others expect of us and our own internal needs and desires.  Social conformity versus going our own way.  Such conflicts are hardly a novel or esoteric concept, and certainly they are well known to all of us.  Yet the term neurosis has almost disappeared from the psychiatric lexicon.  A huge mistake, in my opinion.

The term neurosis was all over the place in the first two editions of the diagnostic bible of the American Psychiatric Association (APA), the DSM, until the DSM III came out in 1980.  Then it was unceremoniously dropped.  To be sure, it had been invoked as a causative factor in disorders and behaviors which we now know it had no business being associated with, such as severe obsessive-compulsive disorder and homosexuality.

Just because it was not one of the major causative factors for some psychiatric or behavioral conditions does not mean, of course, that it is not a major causative factor in any of them.  Surely all of us think twice about doing what we want to do when we might be disowned by our parents or thrown in jail if we indulged ourselves.  Yet we still have our own powerful personal needs and desires.  That such conflict creates anxiety in us which can lead us to some strange compromises is almost indisputable.

But starting with the DSM-III, the powers that be wanted the list of psychiatric disorders to be merely descriptive and not get into the highly controversial area of what actually causes them (etiology).  Saying intrapsychic conflict is a major cause of a disorder is just psychoanalytic theory, so the reasoning goes.  And analysts have without a doubt been wrong about a great many things.

So psychiatrists are now stuck with the only official list of diagnoses in medicine that avoids the whole question of the causation of disorders.  It's like a compendium of the symptoms of infectious diseases that never mentions viruses, bacteria, or parasites!

Wednesday, December 8, 2010

How to Disarm a Borderline: Part IV: The Kernel of Truth

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29) and Part III (November 24).  In this post, I will begin to run down specific countermeasures to the usual strategies in the BPD bag of tricks used to distance and/or invalidate you, as well as to make you feel anxiously helpless, anxiously guilty, or hostile.

When people with BPD try to distance you (again refer to my Distancing: Early Warning post of July 6), you can use the momentum generated by their attempt to push you away to actually move closer to them in the emotional sense. The idea is a bit like the philosophy of Judo, in which the momentum of an attack on you is converted into something used against the other person - with one exciting exception (apologies to C&R Clothiers for my boomer fans in LA) . In dealing with BPD, the goal is for both sides to win.


Tone of voice is crucial.  You can use the same, and exactly the right, words and sound as if you are indeed feeling helpless, guilty or hostile, or you can sound like you are at peace with yourself and with your own limitations.  Since this post is not an mp3 you can listen to, I will do my best to describe how you should sound. 

You should make any of the counter-statements described below sound completely matter-of-fact.  You should sound warm but not condescending, and like you are taking the opinion of the person with BPD seriously even if you do not agree with it. 

#1:  Wild accusations and exaggerated overgenereralizations.  When those with BPD make overly dramatic, hyperbolic statements or accuses you of having ulterior motives for what you are doing or saying, they are literally inviting you to invalidate them (See my post Validating Invalidation from September 23). 

What is going on here is that, since people with BPD have usually been invalidated on a recurring basis by their family of origin, they respond by making it easy for those people to continue to invalidate them.  And they will often practice this skill on lovers and mental health professionals, or even on innocent bystanders when those bystanders try to be helpful. 

I know it is hard to believe that they have an altruistic motive for behaving the way they do.  They will not usually admit to it, and if they do it will be in a disguised and very subtle manner so you will likely misunderstand what they are saying.  I explain the biological reasons why we are all willing to sacrifice ourselves to our kin group in my books, How Dysfunctional Families Spur Mental Disorders, written for the lay public, and A Family Systems Approach to Individual Psychotherapy, written for therapists.  Most people in the mental health field do not agree with this idea.

In countering this ploy, the idea is to resist the invitation to invalidate them without agreeing to all the exaggerated histrionics or without agreeing that you are some kind of schmuck.  Remember, disagreement and invalidation are not the same thing.  The key:  no matter how awful or crazy-sounding what they say is, there is always a kernal of truth in it.  Always, no matter how small.

The countermeasure, taught to me by the best professor in my residency program, Rodney Burgoyne, is therefore to validate the kernal of truth in the statement and simply ignore all the exaggeration and the negative implications.

Let's start with hyperbole or exaggeration.  My favorite statement of this sort of all time is "Life is a sh*t sandwich, and you have to either eat it or die!"

Eeewwww!  The temptation here to reassure the person who says this that things can not possibly be that bad.  Wrong move.  The counterstatement should be something like, "It sure sounds like you've been having a pretty bad time of it."  Trust me, anyone with BPD is frequently quite miserable for very valid reasons.

Or how about, "Why bother going to a therapist?  They're only in it for the money!"  I used to hear that as an accusation as in, "You don't care about me, you're only in it for the money!"  I could get all defensive sounding and say, "Well you know this is how I make my living!" or I can say very matter-of-factly, "Well, after all this is how I make my living." 

I always thought it was better for the patient to have a highly paid professional therapist rather than an amateur.  The amateur would be too busy out making a living to have much time to devote to the patient's therapy and learning how to be a good therapist.  You get the idea, though.  If you want the patient to get help, you say much the same thing in the third person.

"You don't really care about me" is a favorite accusation of people with BPD that is very hard to validate.  After all, how can you really prove that you care about someone?  You could argue til the cows come home and you still could not prove it.  In truth, there is literally no way to prove it. 

So why bother? Besides, at those times during which they are giving you a really hard time, in actuality you don't care, or wish you did not.   I usually reply, "I wish there was something I could say that would convince you that I do care."

Another type of accusation is more indirect and has trap within it.  Someone in LA, for example, might say, "Anyone who is willing to put up with this horrible smog and traffic is a moron."  Assuming that you happen to live there, this statement in effect classifies you as a moron.  If you agree with it, you are saying that you are one.  Of course, if the person with BPD also lives in LA, he or she is also admitting to being an idiot, so if you agree, you are insulting him or her as well.  So what's the kernel of truth? 

Are smog and traffic bad things?  If you answer no to this question, I would have to question either your sanity or your sincerity.  The counterstatement: "Yeah, aren't those things a bitch!"

Coming up in the next post in this series: #2, countering escalating demands on you to do more and more.

Friday, December 3, 2010

Excerpts From My Book Online

There is still no "Look Inside" feature on Amazon.com about my book, How Dysfunctional Families Spur Mental Disorders: A Balanced Approach to Resolve Problems and Reconcile Relationships (I am still bugging the publisher), but if you want to take a peak, you can at Google books at http://books.google.com/books?id=NRFfrE9WlQ4C&printsec=frontcover&dq=How+dysfunctional+families+spur+mental+disorders&hl=en&ei=O6_5TODcDoeglAfZpKzhBw&sa=X&oi=book_result&ct=result&resnum=1&ved=0CDIQ6AEwAA#v=onepage&q&f=false

Thursday, December 2, 2010

My Name is Sue! How Do You Do?!!


In my post of June 17 about the movie Thirteen, I wrote about how screenwriters for motion pictures occasionally nail a psychological phenomenon.  Many of them are way off base, but on these rare occasions one seems to be more knowing than many psychotherapists.

Today I would like to highlight some song lyrics that are similarly knowing, and concern a phenomenon that very few therapists even think about - hidden altruism in what seems to be, for all intents and purposes, a very cruel act by a family member.  The song also illustrates how learning more about what makes other family members do what they do can change your entire perspective on your own life.

The song in question is "A Boy Named Sue," which was sung by Johnny Cash and written by the multi-talented Shel Silverstein.  The song was meant to be just a humerous story, and what happens in the story itself is probably unlikely to ever take place, but the general idea is a wonderful illustration of the phenomenon I am highlighting.

The song was originally released in a live version in front of inmates at the infamous San Quentin prison in California.  You can hear from the audience reaction to the lyrics that some of prisoners were quite possibly identifying with them.

The song tells a story about a man whose father abandoned the family when the man was three years old.  Just before leaving, the father named his son "Sue."  Of course, from then on he is relentlessly teased and ridiculed for having a girl's name, and is constantly getting into fights because of it:

         Some gal would giggle and I'd get red
         And some guy'd laugh and I'd bust his head,
         I tell ya, life ain't easy for a boy named "Sue."

The protagonist's anger that his life has been so difficult leads him to resolve to track down and kill his father for doing this to him.  He finally finds his Dad at a bar in Gatlinburg, Tennessee and announces his presence:
       
        And I said: "My name is 'Sue!' How do you do! 
        Now you're gonna die!!"

What follows is a graphic descripiton of the fight they get into "kicking and a' gouging in the mud and the blood and the beer."  Finally, the protagonist gets the upper hand and pulls a gun on his father.  He is about to kill him when the father explains that, although he understands his son's anger and would not blame him for shooting, he had give the son the name because he knew he wasn't going to be around to protect the boy and that the name would force the son to "get tough or die:"

       But ya ought to thank me, before I die,
       For the gravel in ya guts and the spit in ya eye
       Cause I'm the son-of-a-bitch that named you "Sue."

Of course, the protagonist then gets all choked up and they reconcile near the end of the song.  The last line is "And if I ever have a son, I think I'm gonna name him  -----   Bill or George! Anything but Sue!"

The father's explanation puts the Dad's behavior in a completely different light that helps the son "come away with a different point of view" about his own experiences.  Of course, it still doesn't excuse the father from abandoning the family in the first place, but maybe there's some sort of understandable explanation - not an excuse - for that as well.

The phenomenon of distancing described in my post Distancing: Early Warning of July 6 often stems from a parent's feeling that his or her children are much better off if they are not in the parent's presence.  In other words, the parents' guilt and low self esteem dictate that they are doing their children a favor by driving them off.  They see themselves as toxic.  If they had been abusive, they know that they have been the cause of a lot of grief for their kids, they may therefore be somewhat more comfortable if their children hate them. 

It is similar in some ways to the famous old Groucho Marx line, “I wouldn’t join any club that would have me as a member.”

If they really want to be helpful to their kids, however, they need to bite the bullet and 'fess up to what happened, apologize as best they can, and try to understand the family dynamics that led to the awful situation in the first place.   I'll provide some guidance in how to go about that in future posts.