Why Are There so Many Different "Schools" of Psychotherapy

 

Head honchos of all the differing schools of thought in psychotherapy met together in 1985.

There are currently hundreds of  different “schools” of psychotherapy, each with their own theories to account for problematic behavioral, relationships, and thought patterns in individuals. Most of them are variations on the six major schools of thought in the field: psychodynamic, cognitive, behavioral, affect-focused, existential, and family systems. Still, they often have completely different ideas about what is important to focus on in psychotherapy, as well as the reasons for their clients' problems.

In 1985, the Milton Erikson Foundation put on the first of several "Evolution of Psychotherapy" Conferences, in which they were somehow able to get all the current head honchos of the various schools (pictured above). I was there and it was impressive to hear them present their ideas and argue with one another. Before I even became an academic and while in private practice, I had done extensive reading and noticed that each of these differing, very complex schools of thought had  valuable things to say about human nature, but that each was riddled with some logical fallacies as well as outright distortions.  I decided to attempt to write a book on what I called a "unified theory," which I somehow managed to get published in 1988.

So why so many schools of thought? In a way, this plethora of theories and methodology is not at all surprising in light of the fact that  psychology is still a relatively young science, and having several theories is typical of new scientific endeavors. In the case of psychology, coming together is particularly difficult because of the sheer number and magnitude of natural processes involved, coupled with the fact that we cannot read minds. When it comes to important phenomena such as domestic violence and child abuse, people lie all the time – not only to others but to themselves as well. They do so out of shame or a desire to protect other family members.

 So-called “empirical” studies in the field are, in a sense, collections of anecdotes: the impression of the researcher coupled with the self report of the individuals being studied. To really know with any certainty what is going on with, say, family interactions , experimenters would have to be able to watch them, over a significant period of time when people were not aware they are being watched. This cannot be done to the extent necessary.

The problems in the field are further made difficult to sort out due to the complex structure of the human brain as well as the sheer number of environmental factors which impinge on it.  The brain has billions of neurons, each with up to about 1000 constantly changing synaptic connections caused by a process called neural plasticity. These connections are further impacted by scores of different genes, which do not determine human behaviors but each making certain behavioral tendencies a little stronger or a little weaker.

Relevant environmental influences probably number in the hundreds and come and go in various and constantly changing combinations and intensities. Then there is the so-called “butterfly effect” in which even small differences in initial conditions lead to major differences later on.

Finally, the complexity of the problems that bring clients to therapy varies widely depending on their specific issues. Some problems are rather straightforward like simple phobias or lack of assertiveness with strangers. Others involved horrendous issues such as a family violence or substance abuse and their ongoing effects. One-size-fits-all interventions such as cataloguing irrational cognitions do not really seem adequate for comprehensive treatment.

Treatment outcome studies have been little help. Generally, all the major treatments come out about the same in terms of efficacy. People in SEPI, a professional group  that looked at these issues, used to jokingly refer to this as the “Dodo Bird” (from Alice in Wonderland) verdict: All have won and all must have prizes. Even then, a significant percentage of subjects do not respond that well, and those that do improve often the improvement does not last for more than a year. When one paradigm is directly compared with another in a study for a given condition, 85% of the time the treatment favored by the person designing the experiment "wins" and outperforms the other treatment. This is most likely to something called the “allegiance effect.” Another issue: sometimes acceptance of an idea in the field is due to the eminence of the experimenter and not due to the actual evidence.

It seems to me that many of these schools of thought assume without real evidence that all the problems of people who are repeatedly self-defeating or self destructive, or who make choices in life that make them unhappy, do so because they are mentally deficient in some way. I have categorized these alleged deficiencies as their being either “mad, bad, or stupid.” That is, insane, evil, or unintelligent.  Non-psychotic clients are usually are none of these things.

Furthermore, as described in a previous post, psychological problems are often seen by practitioners and theoreticians alike as existing only in people’s heads, as if the client’s current social and relationship environment is almost irrelevant.  For example, in studies of the alleged over-reactiveness of people diagnosed with so-called borderline personality disorder, subjects keep diaries of when they have strong emotional reactions – “ecological momentary assessment” – but are not asked to also write down what it is they are reacting to.

In the 1980’s and 1990’s, family systems schools began to address this deficiencies – but then they went to the opposite extreme by viewing clients entirely as pawns of their kin groups with no capacity for critical thinking and independent decision making.

Psychiatry, in the meantime, has swung back and forth between, as L. Eisenberg put it back in 1986, brainlessness (Freudian psychoanalysis, for example) and mindlessness (eugenics in the 1930’s and the over-estimation of biological psychiatry in the present).

There are a few of use who are still trying to put all these various ideas together in some sort of valid and coherent form. Gaining acceptance by the field for these efforts is an uphill battle.

New Study Questions History of Childhood Trauma in Borderline Personality Disorder

Despite protestations in some quarters that it’s just a brain disorder and that’s all, almost all studies of subjects of borderline personality disorder (BPD) show a significant percentage of them were found to have a history of child abuse, including physical, sexual, and psychological. Since research subjects may not all be truthful about matters like that, the percentage is probably higher than those reported. Frank abuse is of not seen in all cases, of course. 

 

In getting to the bottom of the family dynamics of my psychotherapy patients over the last 40 year, I discovered that some of their parents are instead hyper-involved yet resentful helicopter parents who try to protect their children from any and all problems – which invalidates their children's ability to take care of anything on their own. Parents invalidating their kids’ thoughts and feelings, posited as one of the causes of the disorder by Marsha Linehan’s DBT – the predominant psychotherapy paradigm for the disorder – is an almost universal feature of BPD families.

 

A good meta-analysis (studies that combine the results of several study to add strength to the conclusions of any one study) that corroborates theoretical proposals that exposure to adverse life experiences is associated with BPD is “Childhood adversity and borderline personality disorder: a meta-analysis” by Porter et. al. in Acta Psychiatrica Scandinavia (2019).

 

A new study, however, seems to show that this is not the case (“Childhood trauma and borderline personality disorder traits: A discordant twin study” by Skaug, et al., Journal of Psychopathology and Clinical Science, (2019). But it has some of the same logical flaws I’ve documented in a previous post. It was a study of “discordant” twins (where one is healthier than the other) and was based on their self report using a structured interview called the Childhood Trauma Interview. Small but statistically significant associations between childhood trauma (CT) and BPD traits were initially found in the total sample. However, after controlling for “shared environmental” and genetic factors in the discordant twin pairs, the analyses showed little to no evidence for causal effects of CT on BPD traits. The authors concluded that the associations between CT and BPD traits stem from common genetic influences.

 

The elephant in the room here is the definition of “shared environment.” The assumption here is that both twins grew up in the same environment, which further presumes that their parents treated both of them the same. As anyone with a sibling or more than one child knows, this is nonsense. Differences in the way the parents treat the two children might even be exacerbated by the fact that one twin is healthier than the other, which could mean they had different parental responses to them at least some of the time. If you assume the shared environment is the same with parents treating both kids the same, of course genetic differences will stand out more. The study also ignores the fact that self reports about childhood abuse are often dishonest in order to go along with family rules about hiding such things from outsiders, so that its data in all likelihood also underestimates the prevalence of adverse childhood experiences, thereby minimizing any differences in the way each twin was treated.

A New Kind of Twin Study and the Heritability Fraud

In my post on Psychology Today, "Scientific Fraud in the Nature versus Nurture Debate," I discussed the disturbing tendency of psychiatric researchers to use the term heritability as a synonym for genetic, which it certainly is not. The heritability statistic is a measure of phenotype, not genotype, meaning it is a measure of the final outcome of the influence of the interactions between genes and the environment on such things as certain personality characteristics or psychiatric symptoms.

The statistic is derived from twin studies in which fraternal and identical twins who were raised together are compared to each other and to those raised apart on various traits. It is not a measure of purely genetic influences but instead a measure of a mix of purely genetic influences plus gene-environment interactional influences. 

There is no way to tell how much of each is present in the statistic. The determination of heritability can also be manipulated in a number of ways, such as by setting the bar for saying that a symptom is present or absent at different levels.

Interestingly, a recent study employing a very different type of twin study has been getting a fair amount of press (Thalia C. Eley, Tom A. McAdams, Fruhling V. Rijsdijk, et. al., "The Intergenerational Transmission of Anxiety: A Children-of-Twins Study," American Journal of Psychiatry, 172 [7], pp. 630-637, 2015).

Rather than comparing twins with each other, the authors compared the children of twins with one another. The subjects were anxiety and a dimension of normal personality known as neuroticism - a measure of emotional reactivity. People with higher neuroticism scores tend to get more anxious and/or depressed in reaction to negative environmental stimuli, and remain dysregulated longer, than those with lower scores.

By comparing the extent to which correlations between children and their twin uncle/aunt (avuncular correlations) differ for monozygotic (identical) and dizygotic (fraternal) twin families, the authors were able to infer the extent to which genetic and environmental factors influence transmission from one generation to another. Children share a greater level of genetic influence with their uncle/aunt when in monozygotic families than when in dizygotic families.

Thus, if children resemble their uncle/aunt to a greater extent in monozygotic families than in dizygotic families, this implies a genetic influence on transmission of the trait of interest. In contrast, if these two sets of correlations are similar, and are significantly lower than the parent-child correlations, this is indicative of an environmental mode of transmission.

The results of the new study showed almost the opposite of the usual results of heritability studies on neuroticism: environmental factors came out very much more important than genetic ones! Living with one's parents was found to be far more influential than merely inheriting 50% of their genes.

It appeared that children and adolescents learned anxious behavior from their parents rather than inheriting a tendency towards it from their parents genetically.

Now, I must say that the authors used a statistical technique to come to their conclusion called "structural equation modeling"—of which I know absolutely nothing. So I am not able to say if the methodological techniques used in traditional twin studies yield more accurate results than those found in this type of study. This may, in fact, be a case of scientists being able to get the results they want to get through statistical manipulation of their study data.

And surely neuroticism must have some significant genetic component. Clearly, some people are naturally more high strung than others.

Nonetheless, I do know from the observation of blatantly obvious behavioral patterns within families and other social groups that anxiety can be highly contagious. Since as of now mental health professionals can't fix your genes but we can fix your relationships, I know on which factors therapists should focus the majority of their attention.

More Astonishing, Cutting-Edge Research in Psychiatry

As we did on my post of November 30, 2011, it’s once again time to look over the highlights from my two favorite medical journals, Duh! and No Sh*t, Sherlock. 

As I pointed out in that post, 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 thought to be true but have yet to be "proven"?  Such an approach increases the success rate of studies almost astronomically.

Psychiatric blogger Nassir Ghaemi agrees: "In some estimates, less than 10% of all NIMH funding is aimed at clinically relevant treatment research on major mental illnesses (i.e., schizophrenia or bipolar disorder). Further, that limited funding is sparingly distributed: the highly conservative, non-risk-taking nature of NIH peer review is well-known."

Here are some of the most interesting new findings reported in these journals.

Side Effects and Therapeutic Effects Are Not The Same Thing

A brilliant new study (http://www.reuters.com/article/2011/12/08/us-depressed-worse-idUSTRE7B72JM20111208) on one anti-depressant concluded: "In the first few months patients either responded to the treatment and improved or didn't and still suffered side effects." Really? People can get side effects from a drug but no benefit? That actually happens?!? I never knew.

Teen Pregnancy Associated with Poverty, Low Education

The Charleston (WV) State Journal (3/27, Burdette) reports that "a report released last week by Auburn University shows that the high poverty levels and low educational attainment among women have a direct correlation to the region's high number of teen births." The media is so irresponsible! Why haven't they pointed out this correlation more often than the previous 13,000 time?

Deployment, not Military Service, Stresses Reservists

What?  Combat is more stressful than merely serving in the military??  But it looks like so much fun.

Listening to Loud Music Associated with Substance Abuse

The Los Angeles Times (5/22, Kaplan) "Booster Shots" blog reports that according to a study published online May 21 in the journal Pediatrics, "Teens and young adults who listen to digital music players with ear buds are almost twice as likely as non-listeners to smoke pot.” As a veteran of the San Francisco music scene in 1967, I just never noticed that the people in the audience at the Fillmore auditorium were smoking pot. I always thought that smell came from the incense they were burning, and that those funny cigarettes were just home-rolled tobacco. Additionally, their LSD use was greatly exaggerated. They were not hallucinating. Those light shows were just really amazing.

And on a related note:

Small Study: Medical Marijuana May Impair New Patients' Driving Skills.

Reuters (7/27, Pittman) reported that although it often goes unnoticed during sobriety tests, the use of medical marijuana at the typical doses used by AIDS, cancer and chronic pain patients causes users who have not yet built up a tolerance to cannabinoids to totter from side-to-side when driving, according to a study published online July 12 in the journal Addiction.  Well I’ll be!  Intoxicants impair driving skills?  Who knew?  Legislatures should look into doing something about this, or someone could get killed.

 Review: Negative Interactions with Staff Common Cause of Aggression on Psychiatric Wards

MedWire (5/26, Cowen) reported, "Negative interactions with staff are the most common cause of aggression and violence among inpatients in adult psychiatric settings," according to a review published in the June issue of the journal Acta Psychiatrica Scandinavica. Now come on!! Patients with schizophrenia are just naturally aggressive. It’s in their genes! Don’t let their completely flat affect and their total inability to organize a break out from a locked ward fool you.

Parental Fighting May Lead to Later Depression, Anxiety in Children

 

HealthDay (6/16, Goodwin) reported that "slamming doors, shouting and stony silences between mom and dad can really scar kids emotionally," according to a study published in the journal Child Development. Investigators found that "Kindergarteners whose parents fought with each other frequently and harshly were more likely to grow into emotionally insecure older children who struggled with depression, anxiety and behavior issues by 7th grade."  Here we go again. This parent bashing has just got to stop. We all know very well that behavior is controlled by genes and that environmental stress has absolutely zero psychological consequences.

And as long as we are on the subject of parent bashing, here’s some more evidence for this horrible trend:

Children's Adherence to Mental-Health Treatment May Depend on Parents' Perceptions

 

MedPage Today (8/4, Petrochko) reported, "Whether or not a child maintains a treatment for mental health may depend on parents' perceived benefits of that treatment," according to a 573-participant study published in the August issue of the journal Psychiatric Services. How many times can I stress this?  Parenting skills are absolutely irrelevant in determining the behavior of their children.

Do Panic Attacks Really Come "Out of the Blue?"

 

Panic disorder (PD) can be a severe, highly disabling and debilitating psychiatric condition. Thankfully, it is usually easily treatable with a combination of medication and a cognitive-behavioral technique known as cognitive restructuring, which I will not describe here.

 

Panic attacks are basically attacks of extreme anxiety accompanied by a variety of physical symptoms which I will describe in a moment. People experiencing them for the first time often think they are having a heart attack, because the symptoms of panic attacks mimic those of a myocardial infarction. They often go the emergency room multiple times. When they get there, the doctors do an EKG and blood tests that would be evidence that the patient was indeed having a heart attack, and lo and behold, all the tests would come back completely normal.

 

In the days before ER docs became familiar with the disorder, patients would be basically told that their symptoms were all in their head and sent home. The patient would be flumoxed. The physical symptoms are of such intensity and acuity that patients would come to the correct conclusion that something physical must have happened.

 

Panic attack symptoms include palpitations (pounding heartbeat), increased heart rate, sweating, tremulousness, shortness of breath, choking, chest pain, dizzyness or lightheadedness, nausea and abdominal distress, a sense that everything is unreal, fear of losing control or going crazy, fear of dying, numbness, tingling, chills, and hot flushes. Symptoms can last for a few minutes or for a few hours.

 

Hyperventilation, or breathing too fast, may trigger many of these symptoms, but not all panic attack sufferers hyperventilate. They still get a lot of the same symptoms. Nothing physical going on? What claptrap!!

 

When people have recurring panic attacks, they are said to have panic disorder, and are at high risk of developing a psychological reaction called agorophobia. This byproduct of panics is more common in women with the disorder than men for unknown reasons. In any event, people with agorophobia become fearful of being trapped and avoid crowds (malls, supermarkets, theaters, sporting events and even church), elevators and other tight spaces, lines, and driving, especially distances or over bridges. Sometimes sufferers become fearful of going outside the house alone, and in severe cases they become completely housebound.

The diagnostic criteria for panic disorder is defined in the DSM-IV-TR are:

Recurrent unexpected panic attacks and:

• The attacks are not due to the direct physiological effects of a substance (such as drug of abuse or a medication), or another general medical condition.

•The attacks are not better accounted for by another mental disorder, such as social phobia (such as occurring on exposure to feared social situations), specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder or separation anxiety disorder.

I italicized the "unexpected" criteria because that is the main subject of this post. But first, I would like to point out that all of the listed physical panic symptoms can also be experienced as part of a rage reaction. Rage attacks are most often seen in patients with borderline personality disorder, a high percentage of whom also have panic attacks.

In fact, the physiology and symptoms of a rage attack are identical to those of a panic attack. The individual's cognitive processes (thoughts and evaluation of the symptoms and what may have triggered them) during an attack may be the only phenomena which distinguish them.

That this should be the case is not surprising. Both panic and rage attacks are a manifestation of the primitive fight, flight, or freeze response in all animals. A fight response would lead to rage, and a flight or freeze response might result from panic. Indeed, it seems that people who have panic disorder have a disturbance of this fight, flight or freeze mechanism that causes it to go off and keep going off even after any threatening stimulus is no longer present. An important, self-protective physiological phenomenon may have gone haywire.

In humans, the ability to think might help an individual to decide whether to run or to fight in the presence of a potentially dangerous or threatening stimulus.

To make a diagnosis of panic disorder, the DSM requires that the individual with panic attacks experience them as unexpected, spontaneous, and uncued. That is, there does not seem to be an environmental event that triggers the attacks.

Rage attacks, on the other hand, are usually thought to be triggered by specific environmental events. If an individual has recurrent rage attacks which seem to be unexpected, spontaneous, and uncued, then a completely different diagnostic label is usually applied to them by psychiatrists: intermittent explosive disorder. I have never seen a case in over 30 years that could not be better explained by another diagnosis.

To summarize, for panic disorder, as opposed to the occasional panic attack, the conventional psychiatric wisdom is that they occur “out of the blue” rather than as responses to environmental threats. If they only occur in the presence of one or more specific environmental threats, say snakes, then the person is diagnosed with a specific phobia instead of panic disorder - a snake phobia in this case.

One caveat is that the idea of panic attacks being "unexpected" refers to the absence of a specific stimulus, not to whether or not the presence of a feared stimulus is expected to be present. If, for example, a snake phobic "unexpectedly" comes across a snake on a hike and has an attack, this would not qualify under the "unexpected" rubric of panic disorder.

Panic disorder might be considered a prime example of something that would pit "biological" psychiatrists against psychotherapists. In people who suffer from panic disorder, the attacks do seem to come out of nowhere. They can be sitting quietly in their house doing almost nothing when one comes on. They can even be jolted awake from them in the middle of the night, without having had a nightmare. A tendency to have panic attacks tends to run in families, so clearly some people are more genetically prone to get them than others.

So does this mean that panic disorder is purely and entirely a brain disease? Is its classification as an anxiety disorder incorrect? Does it have nothing to do with chronic stressors?

In my opinion, the answer to all three questions is a resounding no. People who are prone to the disorder do indeed seem to have to have a problem with the internal regulation of their flight or flight mechanism, to be sure, but environmental factors do, in my clinical experience, determine whether such a person has an occasional attack or has a lot of them.

But if attacks happen without a fearful stimulus being present, how is this possible? My theory is thatpeople who are genetically prone to them will start to have them when they are chronically anxious. Whenever they are on guard, on edge, walking on eggshells, or disturbed about something, they then can have a panic at any time during the whole period they feel that way. Why they happen at any particular time remains a mystery.

Now comes a study which adds a lot of credence to the opinion I have formed over the years (Ethan Moitra et al, Journal of Affective Disorders, in press). The study results show that, instead of an immediate reaction, stressful life events (SLEs) in patients with PD can cause a gradual, but steady, increase in panic symptoms over time.

The investigators note they expected to find that panic symptoms would spike immediately after a stressful event and then taper off, but this was not the case. In analysis of more than 400 patients with PD from the Harvard/Brown Anxiety Research Program (HARP) study, panic symptoms worsened progressively over 3 months after participants experienced specific SLEs, including serious family discord or being fired.

What this study tells clinicians is that they need to be aware that, although people may have an immediate reaction, be vigilant in keeping track of how patients are doing over the next few months after the event, and perhaps even longer," according to lead author Dr. Moitra quoted in a Medscape article.

So most patients with panic disorder, even if the symptoms are extremely well controlled with medications as they often are, should also be offered psychotherapy to learn better coping skills to handle the stressors they are experiencing. Otherwise, they will most likely never be able to get off the medication. Not offering or referring for therapy in these cases is disgraceful.

I almost always find that anyone who seems to be experiencing any long term, ongoing anxiety symptoms and/or unhappiness is usually in the middle of ongoing repetitive dysfunctional family interactions. If the doctor does not specifically ask about them, the patients is unlikely to bring them up.

It's the Relationship, Stupid!

Two of my friends recently e-mailed me an article in the New York Times by a Psychiatrist named Dr. Richard Friedman entitled Accepting That Good Parents May Plant Bad Seeds (http://www.nytimes.com/2010/07/13/health/13mind.html).

Before I could blog about it, I noticed that my fellow family issues blogger, pediatrician Dr. Claudia Gold, had beat me to the punch, with an absolutely spot-on critique of the article entitled, Neither Bad Parents Nor Bad Seeds (http://claudiamgoldmd.blogspot.com/2010/07/neither-bad-parents-nor-bad-seeds.html).

Still, I did not realize just how pernicious Dr. Richard Friendman's column was until I saw a comment on Claudia's Blog from someone calling himself J.C. He made the comment that the column made a strong implication that "Children are not dynamic, they can come broken just like computers, without any inherent ability to adapt." Reading the column again, I saw that it implied that the "son" described in the article had apparently come into the world with a heavy genetic loading for rude behavior!

His opinion: "the fact remains that perfectly decent parents can produce toxic children." Toxic children? The very phrase reminded me of Susan Forward and Craig Buck's famous (and still selling) 1989 self-help book, Toxic Parents: Overcoming Their Hurtful Legacy and Reclaiming Your Life. While Dr. Forward did hold out some hope for the adult products of abusive family environments reconciling with their parents, many therapists took note of the title and started advising their patients to divorce their "toxic" parents in order to feel better.

That sounds like good advice until you read the attachment literature. It shows that the best predictor of how well your relationship with your own children will turn out is the nature of your relationship with your own parents. This happens regardless of whether you remain in continuous contact, or not. In fact, since you unfortunately carry your parents around in your head forever (regardless of whether either you or they wish it so), "divorcing" your parents may not prevent the intergenerational transmission of highly dysfunctional family patterns. It may in some cases actually help foster it.

An awful lot of my patients try awfully hard to be the "unparents." They vow they will never treat their children the way that their parents treated them. Unfortunately, they tend to go to the opposite extreme and often end up with kids who have the same problems they do, or who have a polar opposite but still related problem.

If they felt neglected by their parents, for example, they may become overinvolved with and overprotective of their children. If you want to know what might be likely to happen if they do that, please read my very last blog post.

If their parents were alcoholics, for another example, they may compulsively drug-test their kids and repeatedly search the kids' room for contraband before the kids have ever done anything - thereby giving their children the inadvertent message that they expect their kids to abuse alcohol. In working on emotional family trees called genograms, therapists sometime see a generation of alcoholics followed by a generation of teetotalers followed by a generation of alcoholics. Try explaining that one with the concept of a genetic predisposition to alcohol. I dare you.

So were abusive parents born toxic children? Was the 17 year old boy described in Friedman's article born to be "...unkind and unsympathetic to people...rude and defiant at home, and often verbally abusive to family members"?

Friedman trots out the ignorant old warhorse explanation that the boys behavior could not possibly have been caused by "bad parenting" because "this supposedly suboptimal [parental] couple had managed to raise two other well-adjusted and perfectly nice boys. How could they have pulled that off if they were such bad parents?"

First of all, who even said that they were bad parents in the first place? Second, parents do not even remotely treat all of their children the same. Anyone with a sibling or more than one child can tell you that. Anyone remember the Smothers Brothers' comedy team schtick, "Ma always liked you best?" They built a huge career around that one routine. Do you think it might have struck a chord with anyone?

In Claudia Gold's blog post, she describes a family that she treated in which a behavior problem that was similar to the one in the Friedman article was present. She describes exactly how and why a negative pattern of interactions between a parent and a child was set in place, despite everyone's best intentions. I highly recommend her post.

Warning: speculation ahead, based on similarities to many other cases I have treated, and which may or may not apply to this one:

In the case of the particular adolescent described in the Friedman column, a clue as to what might have happened in this family was the observation Friedman himself made that ""it was clear that her [the mother's] teenage son had been front and center for many years."

Maybe too front and center. If the parents were obsessed with their son's negative attitudes and repeatedly lectured him about them ad nauseum, they may have unwittingly given him the message that they would be disappointed if they were deprived of the right to go on lecturing him. In response, he might continuously give them that opportuntity by maintaining the bad attitude.

In addition, it is possible that the parents gave signs to the boy of covert approval when he was rude to other family members. A son sometimes takes on a role that psychotherapy integrationist Sam Slipp called the avenger, in which he acts out his parents unacknowledged and for them forbidden hostility. This allows the parents to vicariously experience the expression of their negative feelings without having to own or be responsible for them.

Psychoanlysists refer to this interpersonal phenomenon as projective identification. They speak of "superego lacunae" or holes in the parents' conscience that prevent them from expressing certain feelings but which lead them to indirectly validate the expression of those very same feelings in their children, even while criticizing the children unmercifully for having done so.

It is not toxic people that create a dysfunctional family, but toxic relationships. Affixing moralistic blame to one individual in the family just makes matters worse. It turns that person into what family systems therapists refer to as the identified patient, when the real patient is the whole group. The identified patient is often a scapegoat.

Even when parents or children do horrible things to each other, labeling them as bad seeds is counterproductive.

In dealing with a toxic relationship, the choice that an adult from a dysfunctional family has is not between self-exile and continuing to put up with abusive behavior. There are types of psychotherapy which can help people repair dysfunctional relationship patterns, solve problems, and reconcile with their loved ones. In my new book, I tell which psychotherapy paradigms are designed to do this. Not all therapists know how. It's not an easy task to detoxify a toxic relationship because feelings run very high, and defenses can be formidable, but it can be done.

IMHO, we need to help put a stop to the intergenerational transmission of dysfunctional family patterns, and these treatments are the best way to do that.

It is interesting that next to Dr. Friedman's article is a still from the 1956 movie, The Bad Seed, about a pretty little girl from a fine family who develops into a young murderess for no apparent reason. Such things, unless a baby comes out brain damaged in some way, happen only in lurid novels and movies.

The Heritability Fraud

As I also discuss in detail in my upcoming book, another way that some "biological" psychiatrists twist the truth in order to justify their belief that certain behavioral problems are due to brain disorders is to try and make a case that they have their origins in genetics. Never mind that there is barely a legitimate neuroscientist alive that believes that any gene or any group of genes specifically codes for any complex behavior pattern in humans that varies widely from person to person.

Most of the "experts" who mislead the field by exaggerating genetic influences do concede that both genetic and enviromental factors play a part in creating behavioral syndromes. They have to, since the rate at which genetically identical twins both show the syndromes is almost never anywhere close to 100%. (Everyone seems to ignore a very important third factor: people's ability to anticipate upcoming events and their consequences and plan accordingly).

What they have done is to come up with a way to apportion these supposed causative factors into genetic and enviromental factors using a statistic called heritability.

Using studies of identical twins that were raised together versus those who were raised apart, they purport to estimate the "variance," or how much each of the various causative factors contributes to a certain disorder. The variance is expressed as a percentage of the total package. Variances are thusly assigned to genetic factors, "shared" environmental factors such as growing up in the same household, and "unshared" environmental factors.

In actuality, a determination of which parts of an environment are shared by siblings and which are unshared has a lot in common with finding water with a divining rod. Anyone foolish enough to think that both parents treat all of their children in anything remotely close to an identical manner must have no siblings and no more than one child.

The even more misleading tactic is to use the twin study statistic called heritability as a synonym for genetic. It is not. The statistic derived from twin studies is not a measure of genotype but of phenotype. Genotype refers to the actual sequence of molecule pairs in the DNA of which an individual’s genes are made. Phenotype, on the other hand, is the final result of the interaction between genes and the environment.

Most of the genes in a cell, even the ones that are at times active in a given type of cell such as a neuron, are in the “off position” most of the time. What turns them on or off are environmental influences. In regards to behavior issues, the social environment is especially important. One of the main purposes of the brain is in fact to interact with other brains.

Heritability is actually a mix of purely genetic influences and gene-environment interactional influences. There is no way to tell how much of each is present in the statistic. The determination of heritability can also be manipulated in a number of ways, such as by setting the bar for saying that a syndrome is present or absent. How much and how often does one have to drink to be an alcoholic, after all?

All human behavior, normal or abnormal, has a genetic component. That's because genes determine what the brain is capable of or incapable of, what it has a tendency to do and a tendency not to do, etc. They provide a range of options. They do not specify what behavior within that range will occur in a given environmental context. To say that genes play a role in creating a behavioral syndrome is a tautology.

In this post I will not go into more detail about what this all means. However, the absurdity of using heritability as a synonym for genetic is illustrated by a recent study published in the Journal of Adolescent Health (V.45 [6]:579-86, Dec. 2009) by van der Aa et. al. They looked at the heritability of high school truancy. The study pegged the "genetic" influence on this behavior at 45%!! Does anyone seriously believe that ditching school is determined by heredity?