Family Dynamics and the Brain: Implications for Psychotherapy

IMO, the most important contribution of neurobiology to psychotherapy is our understanding, albeit quite partial and preliminary, of the mechanisms by which we are programmed to respond to attachment figures. This understanding is sort of what is meant by sociobiology, if I may use a politically incorrect term. 

I found early on in treating personality disorders in therapy that I was no match for a patient’s parents in triggering or reinforcing their problematic (or even their positive) behavior patterns in the long term. I could coach them on how to be assertive with difficult family members ‘til the cows came home, and this might even work for a time, but after a while the old patterns of self-defeating behavior almost invariably re-emerged unless something was done about this.

Even so-called “oppositional” behavior follows this path: oppositional children think and later automatically respond to their family as if the family wants or needs them to be a black sheep for various reasons.

Therapy outcome studies seldom follow patients with self-destructive or self-defeating behavior patterns for more than a year after therapy ends, but the few studies I’ve seen that do are consistent with this clinical experience. So I had to figure out a way to help patients to make changes in their long term repetitive dysfunctional interactions with attachment figures.

When mothers and their babies interact, huge numbers of synaptic connections in the brain are made every second (see https://developingchild.harvard.edu/science/key-concepts/serve-and-return/). These large numbers are “pruned” significantly during adolescence. We don’t know exactly how or why certain synapses are retained, but I suspect it is those that keep us aligned with the social behavior of our kin group and tribe. There is preliminary evidence that the pruning is dependent, much like the strength of many brain neural connections, on how often a particular neural pathway is stimulated.

Another factor involved is something called the myelination of neurons in existing neural pathways. This is the process of coating the body of each neuron with a fatty coating called myelin, which protects the neuron and helps it conduct signals more efficiently. This process does not become complete until an individual reaches late adolescence.

With these two processes, we lose some flexibility in the brain, but the proficiency of signal transmission improves. Since we are talking in particular about those that form during interactions in infancy, it is reasonable to suspect that these interactions continue to do this. In particular, behaviors that occur in response to social cues may become more automatic in order to preserve higher thinking ability for novel situations.

In addition to this, fear tracks formed early in life in particular are not as plastic as are other tracks in the brain. They never really go away, although they can be overridden by newly formed neural pathways. (Lott, D. A. [2003]. Unlearning fear: calcium channel blockers and the process of extinction. Psychiatric Times, May, 9-12).

According to Neuroscientist David Eagleman on his PBS show, The Brain, about 80% of our behavior is done automatically in response to environmental cues (especially social cues, I might add) without any conscious deliberation. In a sense they are subconscious.

This does not mean that we lack the capacity to decide to think about and break the social rules we are usually bound by. We certainly can – this is where the family systems theorists have been wrong. But when we do, we are often faced with massive invalidation by our families, which is extremely powerful in delivering the message, “You’re wrong, change back.” When we distance ourselves from our social alliances, our level of the attachment hormone oxytocin dips and we start to feel unsafe.

The negative feelings generated by this invalidation is probably the biological price we pay if we don’t: the highly disturbing feeling of groundlessness described so eloquently by Irvin Yalom. This is nature’s way of telling us to behave ourselves for the good of our kin group. This has survival value for the group.

The implications for therapy are clear. In order to prevent problematic automatic behavior patterns that have been and that are continually reinforced through this powerful process, neither insight into which behaviors are performed automatically, nor which automatic belief systems keep us on the straight and narrow for our kin group, is usually enough. These patterns need to be interrupted at their source in order to help patients extinguish bad habits of thinking (or, more often, not thinking) and behavior. 

Who's in Charge in Families, Parents or Children? A Paradox

In a recent column, my favorite parenting columnist John Rosemond asked a mother and father, “Who are the most important people in your family?” They replied, as many of today's parents are wont to do, “Our kids!”

Rosemond essentially read them the riot act:  “There is no reasonable thing that gives your children that status... many if not most of the problems they’re having with their kids—typical stuff, these days—are the result of treating their children as if they, their marriage, and their family exist because of the kids when it is, in fact, the other way around... without the parents, their kids wouldn’t eat well, have the nice clothing they wear, live in the nice home in which they live, enjoy the great vacations they enjoy, and so on.

He added: "This issue is really the heart of the matter. People my age know it’s the heart of the matter because when we were kids it was clear to us that our parents were the most important people in our families. And that, right there, is why we respected our parents and that, right there, is why we looked up to adults in general."

I absolutely agree with Rosemond that the parents' marriage should be the most important relationship in the house—not the relationship between the parents and the kids—and that the parents should be the authority figures in charge. The idea that this is the proper hierarchy within the house is in fact the basis of one of the more effective forms of family therapy, Salvador Minuchin's structural family therapy. 

On the other hand, I do have a slightly skewed take about the phenomenon of parents thinking their kids should be the most important people in the house that differs slightly from Rosemond.

The part I disagree with him about is when he say that, because of the parents' behavior, it is no longer clear to children these days that the parents are in charge. In fact, our brains are biogenetically programmed to put our primary adult attachment figures in charge. Our very survival depends on it.

When the children seem to be in charge, I believe they are just acting like it is not clear to them who is in charge, and are acting as if it is they, and not the parents. So how to explain the paradox? It may seem confusing, but it is actually quite simple. 

If children do in fact know that parents make the important decisions in the home, and the parents in their wisdom have decided that the children are more important and that the children's choices should be paramount, then who are they to question the parents' judgment? They will go along with it: They will act like they should make all the decisions, because doing so is in line with precisely the important decision the parents seem to them to have made.

Where the Analysts Went Wrong: Part II

In the introduction to this post, I mentioned that a major problem with psychoanalytic formulations concerning the origins of personality dysfunction is that they presume that problematic interactions with parents and other family-of-origin members are only powerful in shaping personality functioning with young children.

When I first started getting interested in family systems ideas and started asking my adult patients about their current interactions with their parents and other members of their families of origin, it soon became clear that some of the interactions followed certain patterns than recurred again and again, and that these patterns served as triggers and reinforcers, as a behaviorist therapist might say, for the very feelings and behaviors that the patients were coming to therapy to try to change. 

Until I started asking about these interactions, as I described in my post Don’t Ask Don’t Tell, the patients had not described them in much detail. When they broke out in tears while telling me about them, however, it became hard for them to deny that the interactions were at least part of what was making them feel bad.

These were patients in individual psychotherapy, so I was not a first hand witness to these interactions, although later I found ways to see them in person. And my psychoanalytic and behaviorist psychotherapy supervisors had not discussed what to do about them.

It seemed to me that if my patients were just more assertive with their families, they might be able to change these problematic family interactions. The behaviorists had taught me about something called assertiveness training, so I tried that. The first time I tried it, I tried to teach a Chicana woman to stand up to her father. She wanted none of that. Wouldn’t even really discuss it. So, I thought, maybe it’s some sort of cultural force that I was up against in this particular case.

So how about with a patient from a somewhat more egalitarian culture? I taught an Anglo woman with traits of borderline personality disorder (BPD) to be assertive with her family. Her parents seemed to be subtly sabotaging her efforts to establish independence from them. When she was doing well, they ignored her. Or more like gave her the silent treatment and a cold shoulder. When she was in financial trouble, however, they were always right there to help out -although strangely they gave money to her teenage son rather than to her!

Every week in therapy she would dutifully practice assertiveness techniques, and would leave the session confident that she could address the issues with her family. The very next week, however, she would come back with her tail between her legs.  Her best efforts seemed to have been totally defeated, and she became even more unhappy than she had been, and even less self-confident.

I discovered that as a therapist I was absolutely no match for this woman’s parents in affecting her behavior, either for good or for ill. And it was not just her. I found out – again and again - that parents were way more potent influences on the patient than I as a therapist could ever be.

Behavior therapists do not seem to have figured out that the interactions of a patient and his or her family of origin are important triggers to many of the complaints that patients come to therapy with. Nonetheless, their behavioral interventions do often change certain aspects of a patient’s behavior, and therefore they feel that their patients are responding to treatment. In fact, if a patient’s family of origin is not too dysfunctional, they are correct. The patients change their behavior and the family basically accepts the change, so everything is cool.

But in significantly dysfunctional families? Not so much. The family therapists were right. The entire family will confront the patient in a variety of ways that all boil down to the message, “You are wrong, change back.” Many times I have even seen relatives such as aunts and uncles who previously had had little involvement with the patient come out of the woodwork screaming, “How can you do this to your mother?!?”  

Sometimes the situation would escalate to incredible extremes, with parents figuratively sticking their heads in the oven threatening suicide in response to the patient’s meager attempt at self actualization, or doing what they want and not what the parents seem to want. 

The psychoanalyst Karen Horney once opined that “basic anxiety” requires a sense of isolation from others, helplessness, and of being surrounded by hostility. Such perceptions and cognitions are closely related to attachment to others in one’s family system. The human brain encodes social events from the family exceptionally well, and is exquisitely sensitive to them.

“But,” I hear you protest, “a lot of patients with personality disorders are highly oppositional to their parents, seemingly doing the exact opposite of what the parents say that they want. So that theory can not be right!"

My answer to that: these people are oppositional to their parents because that’s what they think the parents need from them. The parents seem to need them to be black sheep. For a further discussion of this point, I refer you to my post about the role of the spoiler.

New developments in neuroscience are consistent with the proposition that parents can have strong effects on their children even as adults, even if they do not want to. Studies have shown that the perception of faces activates specific cells in the amygdala, which is the part of the brain responsible for fear reactions. Different cells there respond to different facial features, and certain cells respond only to one parent or the other. 

The amygdala is also strategically located for generating a rapid and specific autonomic nervous system and endocrine pattern in response to complex social signals. Lesions of amygdala in primates cause an inability to appraise social signals from other members of same species. An afflicted individual cannot distinguish whether another member of their species is coming towards them to fight with them or to mate with them. And again this is in adults, not juveniles.

In general, the attachment system seems to be one of the most important regulators of overall arousal. The amygdala is the first responder within fractions of a second; one’s initial fear orientation is not affected by conscious cognition. However, the signals then go to the other areas of the brain for further evaluation. Information regarding social context directly affects this appraisal process.

Attachment research indicates that the brain regions that compose the limbic system use input from the emotional states of attachment figures to regulate both internal and external responses. Individuals exhibiting so-called disorganized attachment have been found to have parents who display both frightened and frightening responses. 

In a sense, rage and panic are both communicated to and conditioned within the offspring of such parents. According to attachment researcher Mary Main, if parenting generates multiple, contradictory models of attachment, this creates a sense of insecurity in the offspring.

Complex limbic system reactions to the social environment have been found to be specific to important individuals within the family. Problematic reactions such as rage attacks can be seen to occur with one parent but not the other! If interactions with primary attachment figures are highly stressful over prolonged periods, this can have a profound effect on the development of a child’s brain that last a long, long time.

Early learning may be particularly difficult to inhibit. In general, it is much harder to unlearn fear than to learn it in the first place – a fact highly consistent with the experience of psychotherapists trying to extinguish chronic anxiety, particularly chronic interpersonal anxiety. 

Extinction of fear responses has also been found to be context specific. If a fear response is extinguished in one context, it may come right back if an animal is moved to a somewhat different environment. If the new environment is similar to another one such as the early family environment, fearful patterns of behavior learned early in life but inappropriate for the new environment may therefore be seen.

So, early influences are very powerful, but that does not mean that later experiences are inconsequential. When individuals grow up, their parents usually continue to act in ways that recapitulate social interactional sequences from the patient's early life experience. This parental behavior automatically both cues and reinforces old but engrained role relationship schemata (mental models of how to respond to different social cues).  

In turn, these reinforced schemata become more likely to be activated in the patient's current social interactions. This leads to reenactment and recapitulation of these patterns in other relationships. This is the basis of what Freud referred to as the repetition compulsion.

As I have described, parental behavior seems to be an extremely potent environmental trigger for previously learned social behavior. This most likely stems from the survival value of coherent group structure in evolution. As psychoanalysts have hypothesized, children internalize the values and role behaviors of their social system, and conformity to the group has in the past continued to have survival value throughout the life cycle.  

Parental behavior has such a powerful effect in triggering old schemata that it does not have to occur with any great degree of frequency in order for its effects to continue. In adults, the reinforcement of schemata occurs in a manner analogous to the learning theory paradigm of a variable intermittent reinforcement schedule. That is, the powerful parental behavior may be witnessed infrequently but unpredictably, leading the patient to continue to react rigidly in ways consistent with old role-relationship expectations.  

A Great Attachment Debate?



It seems as though the nature versus nurture argument will go on forever, even though we now know a great deal about how the two of them interact in order to affect human behavior.

In the March/April issue of the Psychotherapy Networker, the cover story is titled "The Great Attachment Debate: How important is early experience?  The "debate" is over the issue of whether or not the quality of the relationship between babies and toddlers and their primary attachment figure has a profound effect on  mental health and relationships when the child grows up.  In particular, "attachment" refers to how secure the child feels and behaves with its primary caretaker.

The  two sides of the "debate" in the issue are represented by Jerome Kagan, Ph.D. on the one hand, and the tandem of Alan Sroufe, Ph.D. and Daniel Siegel, M.D. on the other. Kagan researches the effects of inborn temperament, personality, and neurobiology.  Strouffe is a developmental child psychologist.  Siegel is a UCLA psychiatrist who wrote a highly influential book called The Developing Mind.



Jerome Kagan




Alan Sroufe



Daniel Siegel

Jerome Kagan thinks that the "pro" attachment side downplays the importance of both cultural influences and inborn, genetically determined temperament in creating an adult's personality and vulnerability to psychiatric disorders.  "Temperament refers to an inborn predisposition to experience certain feelings and display particular behavior during the early years," he explains. 

The intial work on innate differences in infants in qualities such as activity levels and reactivity was done by child psychiatrists Stella Chess and Alexander Thomas.  The temperament issue represents the "nature" side of the nature-nurture debate.

The "nurture" side of this debate centers around the thesis that the emotional quality of our earliest attachments is a far most important influence on human development than inborn temperament.  Attachment theorists pay particular attention to something they call attunement, which they believe is more important in creating the quality of the infant's attachment than, say, the mother's general traits such as maternal warmth.

Sroufe and Siegal explain, "Attunement, or sensitivity, requires that the caregiver perceive, make sense of, and respond in a timely and effective manner to the actual moment-to-moment signals sent by the child."  The parent has to figure out, for example, how much emotional stimulation a baby needs at any given time.  Too much or too little can disturb the baby, and the baby's need is not a constant but varies widely over even brief periods of time.

I think this whole debate is somewhat silly and depends for its existence on an assumption about attachment that really does not make a lot of sense to me, as I will describe shortly. 

So what do I think is more important in human development, inborn temperament or attachment relationships?  Well first of all, both of these variables always contribute to development.  Second, inborn temperament itself affects and alters attachment patterns.   For example, a colicky infant with an insecure  and anxious mother is a bad combination, while the same mother with a quiet child may do a lot better parenting job in regards to attunement.

The answer to the question as to whether temperament or attachment patterns has the greater effect on ultimate development is, as with almost any question in psychology, it depends.  If the family is accepting and validates the innate predispositions of the child, you get one result.  If they invalidate and denigrate them, you get an entire different result.  The way the child acts also can elicit invalidating reactions from peers and teachers, leading to a sort of self-fulfilling prophecy, as Kagan points out.

Neither side talks about the importance of the choices a person makes, the reasoning they use, or their problem solving strategies in the determination of how a person ultimately acts.

Furthermore, the attunement of the parent to the baby, and what behaviors the parents validate or invalidate, can be quite different at different times. Plus,  there are literally hundreds of other influences on the child which also vary in time. 

With all these factors at work, there is also an effect from what scientists refer to as chaos, in which small changes in initial conditions can lead to big differences in complex phenomena like human behavior later on. This is known as the butterfly effect: the presence or absence of a butterfly flapping its wings could lead to creation or absence of a hurricane. 

It is interesting that the debaters do seem to agree on some points.  Both agree that serious neglect or abuse of infants during their first year or two of life can harm the child's future psychological development. 

I actually disagree somewhat and think that infants are more resilient than they seem to think.  For example, say the mother had an untreated post-partum depression during a baby's early life, but then got treated and became far more attuned to the child.  Chances are, any ill effects of the child's experience during the first two years of life would then be reversed.

 
In this vein, both sides also agree that human psychology can change depending on later experience.  If it could not, then they would both have to think that psychotherapy would be a complete waste of time.  They agree that neither biology nor parenting experience is destiny.  I should certainly hope so.  If we could not adapt to changing environments, our species would have died out eons ago.

Kagan also says another important thing which sometimes gets lost in nature versus nurture debates. Genetic influences on behavior do not determine later personality variables so much as limit them.  This is easier to see with physical traits.  No matter how much Danny DeVito might have trained as a young man, he would never have been able to swim as fast as Michael Phelps did.  Wrong constitution!  This does not mean, however, that training would not have improved DeVito's lap times.
 
A hidden assumption in the whole debate that drives me bonkers is that the most salient patterns in the primary relationship between children and their parents somehow no longer influence a child past the age of two.  Or if you are a psychoanalyst, past the age of five.  Attunement, invalidation, the interactions between the temperaments of parents and children - in short, all of the most salient aspects of their relationship - often continue on and on in slightly altered forms, almost until somebody dies. 
 
If you study the "persistence" of temperament and the security of attachment from childhood to adulthood, and draw conclusions based on just what happened in the first two years of life, you ignore this fact.  If a two year old has an insecure attachment with an unattuned mother, but is taken away from that mother and raised by someone else, you would get a very different view of this "persistence."  Similarly, if you limit the effects of attachment to only early attachment, you are ignoring the effects of extremely important family dynamics all through childhood and early adulthood. 
 
Both sides in the "debate" define attachment the same way.  Since controlling for all the variables is impossible, findings in the research literature will often conflict with each other.  Depending on how studies were structured, it is easy to find studies that over-estimate the importance of attachment in the first two years, and others that under-estimate it.   If on the other hand you assume that the early influences might continue on in time, and determine what they actually were, the "debate" all but disappears.

Debunking De Biederman

Joseph Biederman, the Harvard guru who advocates for the use of antipsychotic medication on children, is a psychiatrist who almost single-handedly started the current craze of psychiatrists and primary care doctors diagnosing acting-out children as having bipolar disorder.  I discussed in previous posts some of the issues involved both in Dr. Biederman's behavior and in the diagnosis of "pediatric bipolar disorder," particularly in my post of March 9, 2010, Recipe for Producing Frequent Temper Tantrums in Children.



Dr. Joseph Biederman

Dr. Biederman argued that the symptoms of bipolar disorder in children are very different from those of adult bipolar disorder.  In particular, he said that manic or depressed mood episodes, required by the DSM to last for a minimum of four to seven days in adults for mania and two weeks for bipolar depression, could last for mere minutes in children. Symptoms of bipolar disorder seen in children but not in adults, he opined, included temper tantrums and "explosive irritability."  Not that he had any clear scientific evidence connecting such symptoms to adult bipolar disorder. I'm guessing he just pulled these ideas out of his butt.

Tantrums, rage, emotional instabilty, low frustration tolerance and the like are all symptoms of borderline personality disorder in adults.  These types of symptoms fall under the rubric of affective instability or mood dysregulation, also called neuroticism by personality theorists. 

Individuals high on this variable get depressed, anxious, or angry quite easily and take much longer to calm down than average person. Patients with borderline personality disorder are frequently misdiagnosed as bipolar in the world of today's psychiatry (see my post of April 7, 2010, Borderline or Bipolar?).

Is similar diagnostic bungling being seen today with out of control children who exhibit affective instability?  Well, according to a new review of all of the existing studies in the February 2011 edition of the American Journal of Psychiatry by Ellen Leibenluft, the anwer is quite clearly yes.

From the abstract: "An emerging literature compares children with severe mood dysregulation and those with bipolar disorder in longitudinal course, family history, and pathophysiology. Longitudinal data in both clinical and community samples indicate that nonepisodic irritability in youths is common and is associated with an elevated risk for anxiety and unipolar depressive disorders, but not bipolar disorder, in adulthood.

Data also suggest that youths with severe mood dysregulation have lower familial rates of bipolar disorder than do those with bipolar disorder. While youths in both patient groups have deficits in face emotion labeling and experience more frustration than do normally developing children, the brain mechanisms mediating these pathophysiologic abnormalities appear to differ between the two patient groups."

In the absence of validated biological laboratory tests for a psychiatric disorder, the time course of symptoms, clustering of the symptoms in close family members, and differences in brain physiology and mental abilities on various mental tasks are the most important indirect ways of assessing whether two similar appearing psychiatric syndromes have something important in common. In each of these ways, comparing short-term affective instability to the longer term symptoms seen in bipolar disorder shows that the phenomena are not the same thing.

It is also important to note that irritability is a criterion for at least six different psychiatric diagnoses in children (manic episode, oppositional defiant disorder, generalized anxiety disorder, dysthymic disorder, posttraumatic stress disorder, and major depressive episode).

Of course, not even Leibenluft discusses the possibility that -  just maybe - affective instability in children is reactive to a chaotic family environment.  Interestingly, in an interview in the January 21, 2011 Psychiatric News, she was quoted as saying, "The phrase we commonly hear from parents is that they have to 'walk on eggshells.'"

 

Translation: the kids in these families are determining what the adults do or say, not the other way around.  A situation in which parents seem to be afraid of their own children is very bad for children, who tend to badly need to be taken care of and given limits by their adult caretakers - despite the kids' protestations to the contrary.  There is very strong evidence from the attachment literature that such situations actually create affective instability in children.

So what might Biederman's answer be to this new data?  Amazingly, according the Leibenluft, Biederman's research group and some other groups maintain that it is "nonetheless reasonable to apply a bipolar diagnosis to children with such a clinical presentation. One important argument for this position is that children with severe nonepisodic irritability manifest severe mood symptoms and are as severely impaired as those with classic bipolar disorder, but without a diagnosis of bipolar disorder their access to the mental health services they need might be limited."  (p.129-130).

Wow. In other words, we should label kids who actually have behavior problems as having bipolar disorder, so instead of doing family therapy, we can treat them with sedating drugs that have not been approved as safe or efficacious in children, and which have a lot of potentially extremely serious toxic side effects (metabolic syndrome) in people including death. 

An amazing display of sick, twisted phony logic worthy of Ann Coulter.

(See a great review of the issues involved in the case of a child named Rebecca Riley who died at the hands of parents who were trying to bilk the psychiatric disability system.  It also shows how easy it is to fool some psychiatrists).

How to Disarm a Borderline, Part I

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If you are an adult in a relationship with another adult, either through blood or through a romantic liaison, who fits the description of a patient diagnosed with borderline personality disorder (BPD), then you already know that you have your hands full.  A New York Times blog post about BPD drew 470 rather contentious comments (http://well.blogs.nytimes.com/2009/06/16/understanding-borderline-personality-disorder/?apage=1#comments) from people who were dealing with BPD relatives and other people who themselves have the disorder.  Although I am in neither category (hopefully), I wrote a few posts myself. 

I wrote about some of the ideas that I describe below.  A couple of people who said they were dealing with BPD parents did not like what I wrote, but showed that they had adopted some of the very behavior they were complaining about in their parents, as evidenced by their responses to me (more on why this might happen shortly).  I was being nice, so I didn't point that out to them.

Some people say that the only way that you will surely survive a relationship with someone with BPD is by cutting all contact with the "toxic" individual.  Some therapists even say this.

If you are in a romantic relationship with a person with BPD, that might indeed be the best course.  Has the relationship already been going on for quite a while?  You won't like hearing this, but this means you: you need to ask yourself why you are attracted to such a difficult person in the first place.  Please don't give me the usual crap like, "I didn't know what (he or she) was like that at first, but now I'm involved and I can't get out.  (He or she) was so charming at the beginning of the relationship!" 

Puh -leeeze!  You are like the wife who insists her husband is not having an affair while she looks for the stain remover to get the lipstick off her husband's shirt collar. Sorry, but most people run at the first sign of BPD behavior.  It is not subtle, and one does not often have to wait very long before one first sees it.

Well, you might object, the person threatens suicide if I tell them I'm going to leave them!  So, let me get this straight.  You're planning to sacrifice your whole life because someone might stab themselves in the heart in front of you and then quickly hand the knife to you before they die so your fingerprints are all over it?  If you feel so responsible for other people that you respond to this kind of threat by caving in to it, please, get some therapy.

When it comes to parents with BPD, however, the strategy of divorcing one's family, while better than remaining in a toxic relationship with them, creates other problems.  First of all, it's kind of lonely to have no family.  You will be faced with a cavernous hole in your life. 

Second, you came from them.  If they are monsters, what does that make you?  You undoubtedly share at least some of their toxic behaviors whether you like to admit to it or not, because one can not grow up in a toxic household without adapting to it in ways that are both problematic themselves and very hard to stop later on in other social contexts. 

Especially with your own children.  Attachment studies clearly show that the best predictor of one's relationship with one's children is......one's relationship with one's parents or other primary caretakers.  Some people from abusive households wisely decide not to have children for fear that they, too, might become abusive.  But is that what you really want to do?

Besides, you cannot completely divorce yourself from your family, because you carry them around with you in your head. Literally. We in the biz call these mental representations schemas.

Your choices are not just limited to these two:
1) To either to continue to be mistreated, or
2) to cut off all contact with your family.

A third choice is to change the nature of your relationship with your parents so that you are not being mistreated but are still in contact with them.  Impossible, you say?  I disagree.  While you do not have the power to "fix" your parents, you do have the power to fix your relationship with them.  If you change your approach to them in a consistent manner, that will force them to change their approach to you. 

However, there is a big problem that you will face in doing this: since you have been in a relationship with them your whole life, they have developed a whole repertoire of behaviors, include recruiting other family members, to give you the powerful message, "You're wrong.  Go back to responding the way you used to."  If one strategy does not work, no worry.  There are plenty more where that came from. Scary to be sure, but not insurmountable if  you can enlist a therapist who knows something about the family dynamics in people with BPD.

Therapists like myself who work primarily with patients with BPD, regardless of their "school" of psychotherapy or their theoretical ideas about the causes and cures for the condition, all have independently developed some ways of getting BPD patients to be more cooperative with them.  (That is, cooperative just with the the therapist. Unfortunately, not with anyone else). We seem to have all come up with these little tricks of the trade independently, yet they are all very similar, as I described in a paper called, "Techniques for Reducing Therapy-Interfering Behavior in Patients with Borderline Personality Disorders: Similarities in Four Diverse Treatment Paradigms" (Journal of Psychotherapy Practice and Research 1997; 6:25-35). 

Marsha Linehan of DBT fame, Otto Kernberg of psychoanalysis fame, Lorna Smith Benjamin of interpersonal therapy fame, and myself (with my not-at-all famous treatment paradigm called Unified Therapy) all do pretty much the same things at the beginning of treatment.  (We then start to diverge considerably).  These strategies are survival skills for us.  Therapists used to come up to me all the time and ask me how I could stand to work with several patients with BPD at the same time, but it really is not a big problem if you know the "tricks."  I had to devise them a long time ago because I built up a private practice by taking referrals of these patients whom no one else wanted to treat.

As I mentioned, it is much harder for someone who is already enmeshed with a relative with BPD than it is for a therapist who has just met a patient with BPD.  One reason is the aforementioned repertoire of behaviors they have designed over many year specifically with you (the enmeshee) in mind.  They know all of your weaknesses and exactly how to take advantage of them.   Second, as a therapist, I do not have to deal directly with a bunch of interfering relatives like the enmeshee does.

The third reason has to do with something behaviorists call a variable intermittent reinforcement schedule.  This schedule is why slot machines in casinos are so successful.  You never know when the damn thing is going to pay off, and it pays off just often enough, so you keep pulling the lever until you lose your shirt.

I should mention that, as John Rosemond is fond of saying, people are not lab rats that blindly respond to rewards and punishments. However, if a person has a goal, and their behavior helps them to reach it, reinforcement schedules kick into play. It is not the person being "rewarded," but the behavior. It is not rewarding to have people hate you.

The goals of the worst of the behavior exhibited by people with BPD, for reasons I will not discuss here, is to cause in their targets one of three reactions.  The first two of these invariably lead to the third.  The three reactions they shoot for in their targets are a sense of anxious helplessness, a sense of anxious guilt, and overt hostility. 

The great big secret, however, is that folks with BPD are often highly ambivalent about getting these reactions.  They will try like hell to get them - and believe me, they are real professionals at it - but they secretly wish to fail. (How do I know this?  Experience.  But I can not prove it - because there is literally no way to set up an "empirical" experiment that would fill the bill - so readers can call this highly speculative if they wish).

If the persons with BPD succeeds at getting one of three reactions, they will continue to draw for it.  Pull out all the stops in order to get them, in fact.  If they fail at getting the reactions, however, they will suddenly become more conciliatory.  However, because of the variable reinforcement schedule, if they only occasionally succeed in getting one of the reactions with a person with whom they have already been interacting for a long time, they will keep trying much longer. 

Therefore, if you already have a history with them, and they have a track record of making you react in any or all of the three ways, their behavior will get much worse before it gets better.  If you can not keep your cool and occasionally react the wrong way, it becomes even harder to get the BPD's to change their behavior toward you than if you react the wrong way all the time!

In later posts, I will share with readers the therapist's tricks for avoiding "rewarding" the bad behavior of persons with BPD, but most people who are already enmeshed with a BPD family member will find it nearly impossible to employ them successfully without the help of a therapist who understands the family dynamics of those who suffer with the BPD traits, and who can prepare them for your "adversary's" formidable defenses.  I will start in an upcoming post with what not to do.

Attachment: the Latest Dirty Word in Biological Psychiatry

The crowd that wants to substitute the “bio-bio-bio” model for the bio-psycho-social model in psychiatry apparently freaks out if anyone brings up the wealth of studies that look at the effects of attachment behavior and attachment trauma on human behavior.

Attachment phenomena are those interactional variables that are present in the relationship between babies or children with their primary caretakers. These patterns affect the child’s psychological development as well as his or her adult intimate relationships.

Attachment patterns are loosely classified as “secure” or “insecure.” Insecure attachments are further subcategorized as “avoidant/dismissive,” “ambivalent/preoccupied,” or “disorganized.”

Clear evidence ties parental behavior problems and parenting styles with subsequent behavioral and interpersonal relationship problems in their children. Those children with disorganized attachments, for example, become overcome with anxiety, confusion, and paralysis whenever they are involved in intimate relationships. The literature shows that the best predictor of how a mother will bond with her child is the nature of the attachment bond the mother had with her own mother.

At the recent meeting of the American Academy for Child and Adolescent Psychiatry in Hawaii, some of the so-called researchers who have been diagnosing bipolar disorder in young children were presenting their material. Peter Parry, an Australian academic psychiatrist who is, to say the least, highly skeptical about pediatric bipolar, relates the following:

“They had no answer to attachment and trauma. Melissa DelBello, when I asked her about her presentation on neuroimaging in Pediatric Bipolar Disorder (PBD) - which was incredibly detailed and actually quite well put together and I complimented her on that – I said that the findings presented seem to have considerable overlap (a phrase she'd kept using about findings with PBD and ADHD) to the neuroimaging findings presented by Alan Schore etc re attachment trauma.

She initially said she didn't understand my question; after repeating it she twice said that there are some differences with ADHD. I eventually had to again repeat that I wasn’t talking about ADHD - I was talking about the amygdala and right frontal changes she was showing with PBD which they also find in the attachment/developmental trauma literature - at which point she conceded they hadn't looked at that population.”

This interchange is typical of the way some researchers who are overly tied to a pet theory attempt to avoid looking at or talking about any data that would call their theories into question. Usually they just avoid answering any questions that would do this, and subtly change the subject. I admire Dr. Parry’s persistence in not letting her get away with that.