Monday, December 28, 2015

Some Questions Answered About Family Dynamics in Borderline Personality Disorder

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

I had an interesting exchange with a reader who asked me some questions about my ideas about the family dynamics of people with borderline personality disorder. I thought other readers may have similar questions, and she gave me her permission to reproduce the exchange in a blogpost. So here t'is, with my answers in blue:

I think my mother has BPD. I am trying to make sense of it, and I am digging into my family's history, to see if I can find a possible cause for her BPD.

The mother of my mother seems to be like the mother in the movie Thirteen, that you commented on in your article. She is always stating she would do anything for her children, but at the same time she sometimes drops things like, 'I sacrificed my life for them." Which pretty much sounds like playing the victim, to me.

It is new to me, that parents who are not physically or emotionally abusive, can also provoke BPD in their offspring. Thank you for attracting my attention to that.  Researching more about this, I read an article that stated that parents who are 'over-involved' can do the same, because they don't allow their children to grow into beings with clear boundaries. Do you agree on this statement? If this is true, than the hypothesis, that BPD patients always have poor attachment to their primary care givers, doesn't stand? 

One last question is: Can patients who have BPD get cured without professional help? I am asking this question, because I realize that I also have had several traits of BPD during the course of my life - although they never co-occurred. Coming to a point where I am realizing that my mother probably has BPD, I am also evaluating my own personality, and if I am honest, I can see that, especially during my twenties, I have had several symptoms, though never more than one at the same time.

Can you please provide me with some clarity ? I would be most grateful. I however will understand if you don't have the time to answer.

In answer to your questions as they apply in general - I am not able to speculate about your situation in particular without having seen and extensively evaluated you and your family situation:

1. The family dynamics of BPD involve the parents being conflicted over the role of having kids. They go back and forth between hostile under-involvement and hostile over-involvement. In a given family, one of these sides may predominate most of the time, but if one waits long enough, the other side shows up.

2. BPD is not a "disease" but a combination of traits by which someone adapts to the above family behavior. Some people have a lot of these traits, some many fewer. The traits can range from very mild to very severe, and severity levels can change dramatically in a short period of time. They can also appear and disappear depending on what is going on in a person's family life at any given moment.

Even in people who show these traits most of the time, many of the traits may start to get better on their own as the person gets older, although certainly not in all cases. Their relationships may continue to be poor, however.  Professional help can be very useful, but whether it's absolutely necessary in every case , the answer is that it depends on a lot of different factors.

Family-oriented psychotherapy is hard to find.  The models I recommend are listed at the end of the post: I'm not sure which ones might be available where you are. In England, the most common one is cognitive-analytic therapy (CAT).

What if no other siblings had symptoms while living in this 'borderline producing family?' Does it make sense to develop symptoms only after having left the parental nest? (Because in this case, the 'spoiler' doesn't develop his behavior to balance the mother's moods: instead she only starts to be a spoiler once married, like my mum ... Then this behavior is of no use? (only to act out own frustrations maybe .. but it is not in the interest of balancing the family system). Does this make sense then ?

(Going to a family therapist in my/my mother's case is a non-option for my mother, so unfortunately I have to kind of figure these things out by myself.)

Again, many possible explanations, so I can't say anything about your situation in particular.

In general, in the type of situation you are describing, the person's spoiling behavior with the new spouse stabilizes his/her parents in some way, but is only needed by those parents when the adult child is in the context of a marriage. Often gender role conflicts and repressed anger are at the root of such a pattern - for example, a daughter might act out the mother's repressed rage about having to cater to her (the mother's) own inadequate husband (the daughter's father or step father). Through the daughter's behavior, the mom experiences vicarious satisfaction of her own rage as she watches her daughter frustrating the daughter's husband efforts to "take care" of her.

If a mother acts in a way that produces BPD in her offspring, is it always the case that the child will become a spoiler? In the particular case of my mother, everyone from her family of birth tells me how "good, quiet, well behaved..." she was. It is like she only started to have BPD symptoms when she got married and had kids. Does that make sense? 

No, not always. In fact, family dynamics are like the proverbial true-false test: nothing happens "always" or "never." There are an almost infinite number of other factors which may alter the developmental course of a child - especially other relationships including the other parent, other relatives, or supportive mentors. There is what they call a "chaos" effect - small differences in initial conditions can multiply into big differences later on. Also, in some families, only one sibling will volunteer and/or be chosen to be "it," while the others remain relatively unaffected. If the "it" child stops playing the spoiler, one of the other siblings may suddenly step into that role ("sibling substitution").  The more severe the parental internal conflict, the more additional siblings will be affected or recruited at the outset.

If BPD is not a disease, how is it that the amygdala in people with BPD seems to be different ?

The amygdala is subject to neural plasticity like many areas of the brain, which means that it normally changes in size and activity as it adapts to the environment - especially the social environment.  It's one of the bases for conditioned responses. See and

Why do almost all of the experts state that BPD is as good as is incurable, even if the patient is willing to cooperate?

"Cure" is a strange word to use since it's not a disease. Borderline traits absolutely can go away, and the relationships of someone with BPD can change for the better, especially with treatment that focuses on family-of-origin behavior.

You say that the traits of BPD sometimes disappear with aging, as they are not needed anymore. But I thought that BPD primarily stems from a fear of abandonment. So I don't see how someone can get rid of this deeply rooted feeling, even when he doesn't live with his parents anymore / is not being abused by them anymore / or maybe they even died. If there is a 'hole' inside you because of non-attachment with your parents, I thought that this emptiness will always be there, and it will just manifest itself by clinging to - pushing away spouses instead of the parents, or the same behavior towards offspring.

The issue of what happens after the parents die is still somewhat of an open-ended question for me.  For some people, they are freed up for the most part, although the "emptiness" never completely goes away. Other people get worse than ever after the parents die, even if other family members do not seem to be feeding into their problems. I think it has something to do with PTSD-like effects. The more obsessive a patient starts out, the more likely they are to obsessively recreate conversations with their parents in their heads. 

I had one patient who got a lot better after seeing the movie A Beautiful Mind. She realized that even though she couldn't stop hearing those conversations in her head, she didn't have to believe them. She discovered the secret of "Acceptance and Commitment Therapy" (ACT) before it had been "discovered" and written about - although I don't think ACT really works if the parents are still feeding into the problem, as they are more powerful in shaping a person's behavior than any therapist.

Are there cases in which a person with BPD manifests traits towards her spouse, but not towards her children? What does it mean?

There are all kinds of different permutations and combinations, and plenty of traits of other personality disorders that can co-exist and come and go with any patient. The family issues that the patient's behavior is designed to solve determines this, and every family is different. The details matter.  The stuff I write about only represents prototypes or the most common patterns.

Tuesday, December 15, 2015

When Anecdotal Evidence is Sufficient Proof

Printed by Publish Any Damn Thing or Perish Press. Research funded by the Keep Unimaginative Academics Employed Foundation.

As I did on my posts of November 30, 2011,  October 2, 2012, September 17, 2013June 3, 2014, and February 24, 2015, it’s time once again to look over the highlights of the latest issue of one of my two favorite psychiatry journals, Duh! and No Sh*t, Sherlock. We'll take a look at the unsurprising findings published in the latest issue of Duh! My comments in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

May 7, 2105. Study: Bisexual And Gay Children More Likely To Be Bullied As They Grow Up

The AP (5/7, Stobbe) reports that a research letter published May 7 in the New England Journal of Medicine suggests that bisexual and gay children “are more likely to be bullied as they’re growing up – even at an early age.” Researchers found that “many of the nearly 4,300 students surveyed said they were bullied, especially at younger ages,” but 13 percent of the 630 bisexual and gay youngsters reported being bullied “on a weekly basis,” compared to just eight percent of the other children.
        HealthDay (5/7, Haelle) reports that “consequences of bullying can include physical injury, anxiety, low self-esteem, depression, suicidal thoughts, post-traumatic stress and negative school performance...said” the study’s lead author. 

This is just more propaganda from people advancing the gay agenda.

6/15/15. Small Study: Lisdexamfetamine May Improve Memory, Concentration Problems Associated With Menopause.

HealthDay (6/13, Haelle) reported that the stimulant medication lisdexamfetamine, which is “marketed for attention-deficit/hyperactivity disorder, might improve memory and concentration problems associated with menopause,” according to a study of 32 menopausal women published online June 11 in Psychopharmacology. The study, which received support from the NIH and Shire, the maker of lisdexamfetamine, revealed that “brain activities such as memory, reasoning, multitasking, planning and problem-solving,” improved while women were taking the medicine.

Hate to break this to the Pharma shills, but stimulants will do that for ANYBODY.

8/4/15. Pediatric brain injuries may be associated with attention issues

The Washington Post (8/4, Cha) “To Your Health” blog reports that youngsters who suffer a brain injury, even one considered minor, may be “more likely to experience attention issues,” according to a study published online Aug. 3 in Pediatrics. For the study, investigators included “113 children, ages six to 13, who suffered from traumatic brain injuries (TBIs) ranging from a concussion that gave them a headache or caused them to vomit, to losing consciousness for more than 30 minutes, and compared them with a group of 53 children who experienced a trauma that was not head-related.” HealthDay (8/4, Doheny) reports that the study found that “attention lapses” suffered by the kids with TBIs “led to lower behavior and intelligence ratings by their parents and teachers.” What’s more, the “loss of focus was apparent even when scans showed no obvious brain damage, the researchers said.”

Because injuries to the brain always improve its performance.

8/18/15. Family Problems Early In Life May Raise Boys’ Risk Of Depression, Anxiety.

HealthDay (8/18, Preidt) reports, “Family problems early in life might raise boys’ risk of depression and anxiety, which is also tied to altered brain structure in their late teens and” into early adulthood, according to a study published online Aug. 17 in JAMA Pediatrics. The study, which “included nearly 500 males, ages 18 to 21,” found that “those boys who faced family problems during” the years from birth to age six “were more likely to have depression and anxiety at ages seven, 10 and 13.” Such boys “were more likely to have lower volume of...’gray matter’ in the brain by the time they reached ages 18 to 21.”

What was Freud even THINKING?

8/31/15. Risky Behaviors May Be Signs Of High Suicide Risk In People With Depression.


HealthDay (8/30, Preidt) reported, “Risky behaviors such as reckless driving or sudden promiscuity, or nervous behaviors such as agitation, hand-wringing or pacing, can be signs that suicide risk may be high in depressed people,” research presented at the European College of Neuropsychopharmacology’s Congress suggests. The study, which involved some 2,800 people with depression, also revealed that “other warning signs may include doing things on impulse with little thought about the consequences.” People with depression “with any of these symptoms are at least 50 percent more likely to attempt suicide, the new study found.” 

This is just silly. We all know that people who are keen to die are risk averse.

10/7/15. Small Study: Older Adults Appear To Recover More Slowly From Concussion Than Younger Patients.

HealthDay (10/7, Preidt) reports that “older adults recover more slowly from concussion than younger patients,” according to a study published online Oct. 6 in the journal Radiology. Included in the study were “13 older adults, aged 51 to 68, and 13 young adults, aged 21 to 30.” All participants were evaluated at the four-week and 10-week mark following their concussions. While “a significant decline in concussion symptoms – such as problems with working memory – was seen among young patients between the first and second assessment,” researchers found “no such decrease in older patients.”

Aw come on. The body always improves with advanced age.

10/14/15.  Psychological Distress May Be Highly Prevalent In Caregivers Of Patients With Advanced Cancer.

Medscape (10/14, O'Rourke) reports that “psychological distress is highly prevalent in caregivers of patients with advanced cancer and is associated with both caregiver and patient factors, researchers the Palliative Care in Oncology Symposium (PCOS) 2015.” Lead study author Ryan David Nipp, MD, said, “Caregiver characteristics that were significantly associated with caregiver depression were being female and having anxiety.” Dr. Nipp added, “Patient factors that were associated with caregiver depression included patients reporting depression, that the goal of their care was to cure their cancer, and using emotional support coping.”

The impending death of loved ones is always such a high!

10/21/15. Parental Involvement May Optimize Therapy For Kids With Disruptive Behavior Disorders.

Reuters (10/21, Rapaport) reports that having parents participate in therapy for youngsters with disruptive behavior disorders may help the children respond optimally to that treatment, according to a meta-analysis of 66 studies published online Oct. 19 in the journal Pediatrics.

Nonsense. We all know that being rude is genetic.

10/28/15. Cancer diagnosis may lead to loss of income, study indicates

The Washington Post (10/28, Blakemore) “To Your Health” blog reports that research indicates that cancer “can take a heavy toll on patients’ pocketbooks, even long after they recover.” The Los Angeles Times (10/28, Kaplan) reports in “Science Now” that researchers found that “in the second year after being diagnosed with cancer, survivors were earning up to 40% less than they had been before they became sick, on average.” The data indicated that “even in the fifth year after diagnosis, annual earnings still had not recovered to their precancer levels.”The findings were published in Cancer.

Because, thanks to the demise of unions, fewer and fewer folks get paid sick days from their job any more. (I'm not being funny).

11/10/15.  Study Supports Raising SSRI Doses in Patients Who Do Not Respond to Low-Dose Treatment

Using a higher dose of selective serotonin reuptake inhibitors (SSRIs) for major depressive disorder appears to be associated with an increased likelihood of response, according to a meta-analysis published today in AJP in Advance. This benefit, which is somewhat offset by decreased tolerability of SSRIs at high doses, appears to plateau at about 50 mg of fluoxetine (250 mg imipramine-equivalent dose). A team of researchers in the United States and London searched PubMed for randomized, placebo-controlled trials that examined the efficacy of SSRIs for treating adults with major depressive disorder and assessed improvement in depression severity at multiple time points.
Er- the first lesson in psychopharmacology 101, I believe.

11/20/15.  Opioid Addiction In Women May Often Start With Physician-Prescribed Medications.

Medscape (11/20, Brooks) reports that new research suggests that the upsurge in the number of women with opioid addiction may be attributed to prescription medicines. Researchers evaluated “sex differences in substance use, health, and social functioning among 266 men and 226 women receiving methadone treatment for opioid use disorder in Ontario.” The researchers found that over half of women (52%) and a third of men (38%) “reported physician-prescribed opioids as their first contact with the” medications. The findings were published online Nov. 9 in the journal of Biology of Sex Differences.

This can't be right. Addiction can only be caused by that evil weed gateway drug, marijuana. Or was that beer?

Friday, December 4, 2015

Book Review: Willful Blindness: Why We Ignore the Obvious at Our Peril by Margaret Hoffernan

In the Hans Christian Anderson fairy tale, The Emperor's New Clothes,  two con men promise an emperor a new suit of clothes that, they said, was invisible to those who were foolish or stupid. When the Emperor parades before his subjects in his new "clothes," no one dares to say that he is actually naked until a child cries out, "But he isn't wearing anything at all!"

Refusal to see the obvious is a characteristic of groupthink, which is a major theme of this blog and a prime concern in my psychotherapy model of unified therapy. It is part and parcel of something that Gregg Henriques calls the justification hypothesis: that we use reason to justify ideas that cement our position within a group, rather than to arrive at the truth. This was also the main theme of Jonathan Haidt's book, The Righteous Mind, which was previously reviewed here.

A wife ignores obvious evidence that her husband is having an affair. Religious people claim to absolutely believe the most preposterous ideas in order to fit in with their fellow church members. Political ideologues seem immune to certain facts no matter how much the evidence mounts, and make convoluted arguments that they seem to believe prove that their ideas are correct. Children in dysfunctional families act out family rules over and over again no matter how much pain it causes them.

In a fascinating book, Margaret Hoffernan dissects this aspect of groupthink and elaborates on all of its myriad manifestations. While concentrating mostly on the madness of employees in business organizations walking together off a cliff in maddening lock step - with the result that the organization is eventually harmed or destroyed (such as Enron, BP  and the derivatives crisis in investment banking that led to the economic meltdown a few short years ago) - she also gives examples from many other walks of life.

Go along to get along. Be silent in order to avoid conflict because conflict might destroy a family or an organization. Rationalize your misbehavior because "everybody's doing it." Once you've laid out your position, never change it in light of new information because you might appear weak. Be a good "team player" and do not ask any hard questions. Avoid changes you might have to think hard about, because it takes a lot less energy and brain power to believe than to doubt.

Then there is something she calls the Bystander Effect: Don't intervene in a crisis if there are lots of people around - surely someone else will take care of it. The more people around to witness a crime, for example, the less likely it becomes that anyone will call 911.

Powerful people are often the most seriously prone to conform to what the author refers to as received wisdom, or information that conforms to stereotypes.

In another fascinating chapter, the author describes people whom she calls Cassandras. These are the folks who refuse to accept ideas just to fit in, often at great personal sacrifice, and are willing to look at the bigger picture to see potential problems that others blithely ignore. The author writes, "...After every institutional or organizational failure, individuals invariably surface who saw the crisis coming, warned about it, and were mocked or ignored."(p. 201). Whistleblowers are examples of such people; the government tries but usually fails to protect them.

The oddest thing about being willfully blind is the fact that people who do this must be aware at some level of exactly what they are doing. As the author states, "How could we know where not to look without looking first?" (p. 88). In order to lie to ourselves, we have to ignore evidence that repeatedly hits us over the head like a two-by-four. Knowledge of a fact can be inferred when someone deliberately blinds himself or herself to its existence.

As the author mentions, we all use two types of thinking: one is automatic, born of habit, fast, and intuitive. If we had to reason out every move we made, we'd be paralyzed. The second form is the one in which we deliberate, weigh pro's and cons, examine evidence, and such. It involves much more energy and takes way more time. A key point about it is that it is also used to monitor the first type of thinking for errors. No one would survive very long without possessing capabilities for both of these types of thinking. Monitoring for errors is always lurking in the background of our minds, even when we are reacting subconsciously, automatically, and without thinking.

Two recent movies, based on actual historical events, brilliantly depict illustrative, startling, and dramatic examples of large numbers of people engaging in willful blindness - and the Cassandras who finally changed things. Labyrinth of Lies shows Germans in the 1950's acting like the Holocaust never happened. Spotlight shows just how many people knew or should have known about Catholic clergy abusing children sexually, and also shows that the higher-ups kept moving pedophile priests from parish to parish - and for a long time no one did much of anything about it.

Facing problems is almost always better than sweeping them under the carpet for the purpose of furthering group harmony. As long as a problem is invisible, it will remain unsolved. As James Baldwin once said, "Not everything that is faced can be changed, but nothing can be changed until it is faced."

Tuesday, November 24, 2015

Depression is a Symptom, Not a Psychiatric Disorder

Lately there have been a slew of articles about "depression" that seem to go out of their way to avoid discussing any specific psychiatric diagnosis listed in the DSM - instead strongly implying that "depression" is itself a disorder. These articles appear in the popular press, but, frighteningly, also in newsletters and newspapers for psychiatrists and psychologists. They explore such questions as "Do antidepressants work?" and "What is better for depression, drugs or cognitive behavioral therapy?"

These types of questions are completely meaningless. Depression is discussed as if it were a single phenomenon that, at best, exists on a continuum from "mild" to "moderate" to "severe." This type of wording is in fact completely ignorant, but does not necessarily reflect real ignorance. In many cases, different entities such as big Pharma have a vested interest in conflating several different psychiatric conditions.

In truth, "depression" is just a mood state, and as a symptom, it can be part of many different psychiatric disorders that are, despite some overlap in symptomatology, as different as night and day when it comes to their clinical presentations as well as their response to various treatments.

To name but a few actual diagnoses, there is major depression (both as part of unipolar and bipolar disorder), dysthymia, adjustment disorder with depression, depression due to a medical condition, and depression due to a substance. Medical conditions that can lead to depressive symptoms include hypothyroidism and some strokes. Substances that can do that include some steroids like prednisone and the "crash" that results when an acute cocaine high wears off.

Furthermore, "depression" as discussed in every day conversation can be a normal mood that is part of chronic unhappiness, or that occurs in response to grief at someone's death or due to any other loss or misfortune.

The most important diagnostic distinction for this discussion is between major or clinical depression and dysthymia. Although we don't know enough about the brain to know the exact causes of either one, and there is some overlap in symptomatology, they appear for the most part with very distinct clinical presentations, especially in their classic forms.

Dysthymia appears to be more of a psychological reaction, while major depression probably involves the more primitive part of the brain called the limbic system. The latter, unlike the former, is accompanied by a whole array of chronic, persistent (lasting all day every day for at least two weeks), and pervasive (coloring all aspects of the patient's mental life) physical symptoms - all at the same time - involving sleep, appetite, ability to experience pleasure, energy level and motivation, and concentration. Sufferers may have an unrelenting and constant sense of foreboding accompanied by inexplicable hopelessness and helplessness. We used to refer to these types of symptoms as vegetative symptoms.

Furthermore, someone in a major depressive disorder episode reacts completely differently to life's every day ups and downs than they do when they are not in the middle of such an episode. It's almost Jeckyl and Hyde territory.

These people stay depressed no matter what life events occur around them. They could literally win the lottery and would not really feel a whole lot better for more than a few minutes.

The most severe form of major depression is called melancholic depression. Most people who have never worked in a mental hospital have never seen a case, but the anti-psychiatry types who have not seen it blather on about depression incessantly as if they knew what they were talking about.

People with melancholic depression exhibit something called psychomotor retardation. People with this symptom move and think at a snail's pace.  It takes them longer to respond to any verbal interactions. They can even appear to have significantly impaired memory, although it is actually a more severe form of concentration impairment. That clinical picture is sometimes referred to as pseudodementia. 

You cannot spend more than an hour with such people without realizing that this condition has next to nothing in common with the type of "depression" people see in their everyday interactions with others, and that there is something seriously wrong with their brain functioning.

In severe major depression, doing any kind of psychotherapy (short of telling them, "take these pills") is a complete and utter waste of time. Sufferers literally do not have the mental wherewithal to deal with any kind of problem solving or other interactions with a therapist. And I say that as a major advocate of psychotherapy.

The symptom of depression in dysthymic disorder, on the other hand, rarely responds to antidepressant medication at all (although the drugs can be useful for other symptoms seen in patients with dysthymia such as panic attacks, obsessive ruminations, and the affective instability characteristic of borderline personality disorder). For these folks, psychotherapy is essential.

In my experience a very high percentage of the people who do drug and psychotherapy outcome studies, at least in adults, make almost no meaningful effort to differentiate dysthymia from major depression by: 1) Not spending any time making certain that patients understand the pervasiveness and persistence criteria that differentiate the symptoms of the two disorders; and by 2) Not taking a complete biopsychosocial history to distinguish psychological from limbic system factors.

All of the fancy biological research is not being complemented by good old fashioned clinical typing.

Furthermore, with the private Contract Research Organizations that do a lot of the studies, experimenters get paid only if they recruit a subject, and subjects get paid only if they get recruited - giving a financial incentive for everyone to exaggerate symptoms in order to qualify.

And people with suicidal ideation, comorbid (other, co-occurring) conditions, and significant personality pathology are excluded from studies. Those "exclusions" eliminate the vast major of subjects that have any of the psychiatric disorders in which depression is a symptom.

Garbage in, garbage out.

By the way, you can also have something called double depression. Such people are generally dysthymic but every so often can have a superimposed episode of major depression. So they have both conditions.

Once a major depressive episode starts to occur, it takes on a life of its own. However, being chronically unhappy, anxious, or stressed out may be risk factors for triggering a major depressive episode to begin with.  If you are genetically vulnerable to an episode of major depression, being chronically unhappy might make an episode more likely.

This is another reason why the question, "Should you treat these people with medications or therapy" is a really stupid question. It's a bit like asking, "Which treatment should people who have extensive, severe, cardiovascular disease get, bypass surgery or high blood pressure medication?" 

These treatments address completely different aspects of the disorder. In major depressive disorder, drugs should be used during the acute disorder, but psychotherapy should be given later to address personality  and relationship risk factors - in order to reduce the likelihood of subsequent episodes.

Friday, November 13, 2015

Parenting: How Criticisms and Nagging Backfire

Children give their parents what the parents seem to need

Mell Lazarus, the cartoonist who created Miss Peach, writes a very creative comic called Momma. I wish it were in a lot more newspapers. He understands something paramount about family dynamics that it seems a lot of so-called parenting experts do not address or even seem to notice. 

Psychiatrists and pediatricians who prescribe medications for children who supposedly have "ADHD" or "Pediatric Bipolar Disorder" never even ask their teenage patients about it - or inquire in any detail about much of anything that goes on at home between them and their parents.

I've included in this post several of his strips that demonstrate how tuned into this process Mr. Lazarus is. The dynamics can be described quite simply in three sentences:

1. If a parent repeatedly criticizes a child or a teenager about the very same behaviors, the child will not only not stop them, but will continue or even dramatically increase them.

2. If a parent continually nags a child or teenager to do the same things, the child will not only refrain from doing what the parent is ostensibly asking for, but will studiously avoid doing so - or even do the exact opposite.

3. If a parent continually tells children or teenagers they have some trait, or lack some trait, the children will compulsively act out the trait they have been told they have, and/or will compulsively avoid doing anything that suggests they actually have any trait they have been told they lack.

So why is this? Well, if parents obsessively do something, children will conclude that they parents either need to do it and/or enjoy doing it, even if the parents repeatedly deny it. Actions speak louder than words. Far be it for any child to deprive a parent of a cherished role.

So, if the parents seem to like or need to nag or criticize, their children will continue to misbehave. If the parents compulsively state or predict that the child has or will develop a negative trait, their children will continue to prove them right. They do these things so that the parents will feel good about themselves, not because they enjoy have negative traits.

Tuesday, November 3, 2015

Where Psychotherapy Goes Wrong

In my post of November 4, 2014, I discussed something called the fundamental attribution error. As described by Richard Nisbett and Lee Ross, this is defined as “the assumption that behavior is caused primarily by the enduring and consistent disposition of the actor, as opposed to the particular characteristics of the situation to which the actor responds.” That post discussed how this error results frequently in mistaken conclusions that are drawn based on studies of people with personality disorders.

It is also the main reason why psychotherapy has not really progressed much as a science in the last 25 years or so.  The 1980's and early 1990's were a period of amazing creativity in the field, during which new ways of looking at human behavior and new interventions to help change that behavior seemed to be coming out every day. In particular, family systems thinkers began to realize that the causes of behavioral problems like self-destructiveness, as well as the causes of symptoms like chronic dysphoria and anxiety, do not reside entirely within the heads of the people coming for help.  

Some of it can be a normal and adaptive response to a very abnormal interpersonal environment. The "attachment" literature, which is fairly strong, shows that kin behavior has a huge effect on the psychological stability and the relationships of all human beings.  Much more so, I always say, than the food pellets and electric shocks favored by behaviorists.

Due to the wide variety of independent factors listed in the masthead of this block, family systems ideas have, unfortunately, been left behind to a significant degree, and therapists are back to looking at people as if their problems were "all in their heads."

Critics blasted systems ideas by focusing disingenuously on areas about which family systems theorists were completely wrong - like the genesis of such real brain diseases as schizophrenia (and yes, the evidence that schizophrenia is truly a brain disease is overwhelming, so spare me the "myth of mental illness" bullcrap). They pulled the usual slick ploy of making arguments based on black and white thinking: if family systems theorists were wrong about some things, then they must have been wrong about everything.

Because the effectiveness of psychotherapy interventions meant to change interpersonal behavior are hard to prove in a treatment outcome study, the systems people were also accused of being unscientific. As if observation were not the first step in the scientific method! (So much for much of what we know about astronomy). "Outcome studies" were touted as definitive proof of various treatment methods, despite the fact that they are extremely limited in their overall validity because there are almost an infinite number of variables that cannot be controlled. And they cannot be double blinded. And the therapists who are participating are not all doing exactly the same thing.

And the studies that are touted show only exceedingly modest effects in those subjects who do improve, as well as showing that a significant percentage of subjects did not get better at all.

Then there is another important fallacy that psychologists discuss: confusing an inference about an observation with the observation itself. Or, in other words, jumping to conclusions, and then acting like the those conclusions are facts. Andrew C. Papanicolaou, Ph.D, a neurobiologist at the University of Tennessee Health Science Center where I used to work, observes,  "Scientific discourse is unique in that it aims to maintain clear distinctions among assumptions, hypotheses and facts and treat each of them appropriately. Although this aim is often attained, it is rarely attained fully and occasionally is not attained at all."

Especially in psychiatry and psychology.

There's this rather big issue of what is really going on with patients, as opposed to what looks like is going on.  If you do not think people have hidden ulterior motives for their behavior, secrets about themselves that they don't want to share, and lack a complete understanding of the behavior of all of those around them who affect their lives, then I am afraid you are living in an alternate universe.

But still, therapists observe their client's performance, and confuse it with ability, as described in a previous post. Even when therapists look at what is basically interpersonal behavior, they make this error. Good examples of this are two of the current "evidenced-based" therapies for borderline personality disorder (BPD), Schema Therapy and Mentalization-Based Therapy. Both posit that people have mental models of how to behave in the interpersonal world, as well as of the motives and intentions of other people in their world. 

In schema therapy, the theory correctly asserts that these mental models or schemas are built up in childhood through interactions with primary attachment figures. It then goes about trying to change those schemas that it identifies as "maladaptive."  Surely, they are maladaptive in some ways, but that they serve no adaptive purpose at all is just assumed.

Although these therapists have started to look at how the primary attachment figures of their patients are behaving in the present , I have not seen much about the fact that schemas are continually updated (through the Piagetan process of assimilation and accomodation) during a person's ongoing interactions with those attachment figures. To understand what is really happening, you also have to look at the schemas of those other people.  The schemas of the various players in the family drama interact with one another!

Mentalization therapy also deals with a person's mental models of the motivations and intentions of other people, but just assumes that the mental models of their patients with BPD are distorted. This is based entirely on the way the patients respond to others, while completely ignoring the motivations and intentions on which that behavior is based. Maybe the patient wants other people to think they have distorted mental models. Why? Because they are playing the role of spoiler. The incorrect assessment of the accuracy of the patient's mental models is confused with the feigned actions of that patient.

Sorry, but we cannot read minds. You have to look at both the behavior and the history of everyone involved, and even then you can get a highly distorted picture yourself. So therapists should quit accusing their patients of what they themselves are doing - distortion.

People who have a history together base their behavior on that entire history, not just what is going on at any particular moment.  And when they talk, they can leave a lot out (ellipsis) and still understand each other, because they both already know what both of them already know. An outside observer does not know these things, and therefore their conclusions based entirely on what is said in front of them can be way off.

Of course, it is true that a therapist can never be absolutely certain of anything. For that, you would not only need a movie camera with sound on all participants 24 hours a day like in the Truman Show, but this equipment would have to be in place throughout the entire lifetime of the patient since birth!  

Still, the more information therapists can gather on the whole picture, the more likely it will be that they will better understand what might be going on and figure out what can be done to change it.

But first, they have to stop their myopic focus on that which is going on entirely in the patient's head.