Factors in the Decline in the Quality of Psychotherapy

Jonathan Shedler

Jonathan Shedler, Ph.D. is a critic of many aspects of today's practices in psychotherapy, and many of his views are similar to my own. He recently listed what in his view are the main factors in the dramatic decline of quality psychotherapy (I thank Dr. Steven Reidbord for calling this to my attention):

Deep intrusion of health insurance agendas into psychotherapy and its training

Dramatic decline in reimbursement. Psychologists in managed care paid 70% less than 1980s. “Best and brightest” now choose other careers

Out-of-control proliferation of for-profit graduate training programs that admit and graduate anyone who can pay

Influx into psychotherapy professions of vast numbers of practitioners who lack adequate training and aptitude

Pharmaceutical marketing/PR campaigns changed public perceptions, normalized meds and seeking MH care from primary care doctors as solution for problems in living

Therapy researchers operate in academic silos with little knowledge of psychotherapy and no contact with real-world psychotherapists. Most “therapy” research irrelevant and useless to clinical practitioners

Conflation of psychological problems with DSM diagnoses (by health insurers and academics researchers both)

Conflation of psychotherapy “outcome” with DSM symptom lists (driven by health insurers and academics researchers both)

Rise of social media therapy influencers and their self-promotion (“the death of expertise”)

Intense politicization of therapy professions; emergence of a training culture that incentivizes “right” politics & ideology over professional competence

Impact of tech companies/private equity. E.g., lowest tier therapists recruited, marketed, paid like Uber drivers. Advertising deliberately erases distinctions between levels of training and experience

Low or no barriers to entry; MH field is low hanging fruit for all manner of self-promoters and opportunists

“Clinical supervision” no longer a clinical training relationship with skilled clinical teacher/mentor, but often reduced to an administrative function by clinics/agencies

Runaway bureaucratization—inordinate time spent on forms/paperwork/documentation/ever-expanding bureaucratic requirements that neither benefit patients nor develop clinical skills in therapists

Extreme gender imbalance in training programs (classes often >90% female) with resulting loss of balance and perspective. Male students routinely report feeling unwelcome/marginalized/silenced

Increased emphasis in training programs on paint-by-numbers “manualized” therapies in place of fundamental psychological principles and core psychotherapy skills

Endless proliferation of “new” therapy brands/models/acronyms instead of emphasis on fundamentals skills. Virtually all are repackaging of well-established principles, endlessly reinvented/rediscovered by people lacking profound knowledge

Rampant denial of the role of unconscious mental life

–and neglect of personality & personality pathology. 

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To those I would add seeing people's problems as "all in their heads" while ignoring family systems and sociocultural issues.

Book Review: The Origins of You by Vienna Pharaon

 

My “Unified Therapy” psychotherapy model, which I’ve been writing about since the publication of my first book in 1988, is meant to treat people who engage in repetitive self-destructive and self-defeating behavior, particularly in relationship contexts. You know, like people who marry one alcoholic or narcissist after another. While looking at their past is essential – in fact I look back three generations to find out why my patients, and their parents and grandparents, act the way they do – what’s even more important is what goes on in the present.

I found that people were acting out roles in their families to stabilize their parents, not for selfish reasons, and were suppressing who they really would want to be if left to their own devices. We all have a tendency to do this due to the effects of an evolutionary process called kin selection. We can choose to do otherwise, but if we do we become subject to terror when our families invalidate us.

Family roles are something modern day therapists pay almost no attention to, so when a book comes out that addresses dysfunctional behavior that dates back to family processes in childhood, I’m keen to read it. The Origins of You by therapist Vienna Pharaon is such a book. She looks at her clients' repetitive dysfunctional behavior in their relationships  as a way for them to feel safe because of earlier interactions with parents. She looks for ways that people do things like act like doormats in relationships – or go to opposite extremes and constantly try to dominate other people.

She addresses five needs from which these behaviors arise, which she says derive from what she calls “origin wounds.” She notes that her clients who had previous therapists often had not mentioned them. The needs which lead to these origin wounds are:

1.       I want to fell worthy.

2.     I want to belong

3.     I want to be prioritized.

4.     I want to trust

5.     I want to feel safe.

After review their childhood history, she uses a lot of popular techniques which are basically supposed to lead to behavior changes after insight into these wounds is achieved, and then has her clients monitor their behaviors for those which lead to conflicts, communication problems, and lack of boundaries. Then they talk about what changes need to be made.

The author claims a fair amount of success doing this, which I don’t doubt. She talks about emotionally abusive parents and a little about physically abusive ones, and domestic violence in the family. But not very much about severe physical abuse and neglect or child sexual abuse which families have refused to acknowledge. In my experience, clients like those who follow the recommendations here would be subject to massive invalidation by their families, which I found eventually and (almost always) undid any positive changes they had made from the type of therapy described in the book.

To her credit, the author does say that these problematic patterns are learned in the family and passed down to subsequent generations. And that the parents also have their own origin wounds, with which I totally agree.

But there are two issues that I (but almost no other therapists) have with her ideas. First, aren’t these people really aware at some level of what they are doing, even when they won’t admit it - even to themselves? Second, are they really protecting themselves, or are they altruistically sacrificing themselves for their parents?

On the first issue, the author does seem to come closer to my point of view in the text and with a couple of her clients. She mentions that a dysfunctional path “is easily recognizable, but sometimes hides in plain sight.” A client named Amir could clearly describe what he was doing but claimed to have no idea why. A long time ago I came to the conclusion that people are not stupid or blind about this, but acted as it they were. To understand what’s going on in my view, check out these posts on a groupthink process called willful blindness.

On the second issue, it’s hard to believe that clients are acting this way because they are protecting themselves, when the patterns are obviously bring them much pain. (There is one selfish motive mentioned above: the phenomenon of existential groundlessness). But as I have said, they are sacrificing their own needs to help maintain family stability.

Which also means that the process going on with the parents continues well into adulthood. The author seems to know this on some level but does not talk a lot about the response of their parents to new changes in the client’s behavior, so it’s hard to judge if she thinks this happens very often. Near the end of the book she does mention only briefly the risk that her clients maybe be “judged, shamed, rejected, or even disowned.”

In general, the author describes these patterns and how to conceptualize them very well, along with techniques which may lead to significant behavioral changes in some families where massive invalidation is far less likely that in those producing offspring with severe personality disorders. 

How Antidepressants Should be Prescribed

 

As psychiatrists are pressured by various business interests to see more and more patients in less and less time, more and more shortcuts have come into practice. Not a good thing. Especially when it comes to anti-depressant prescribing practices. The drugs have become way over-prescribed, and antipsychotic medications are added to them for "augmentation" far more often than necessary. I’ve spoken about the use of symptom checklists, which are screening tests and not diagnostic tests, being used to make diagnoses.

Another recent development has been companies that offer various “genetic testing” to try to predict which medications might work best in a given patient, or what side effects they are likely to get. For example, GeneSight Psychotropic offers a “pharmacogenomic” test which means that it analyzes how your genes may affect medication outcomes. They say: “The GeneSight test analyzes clinically important genetic variations in your DNA. Results can inform your healthcare provider about how you may break down or respond to certain medications commonly prescribed to treat depression, anxiety, ADHD, and other psychiatric conditions.”  

The problem with these tests is that their predictive validity is actually quite poor – even the company admits that “It is important to note that not all patients who received a GeneSight Psychotropic test experienced improved outcomes.”  According to two docs at the NYU School of Medicine, "The tools were developed using small sample sizes, focusing on specific patient populations...and were not tested in real world settings different from the one in which they were developed."

The tests are IMO a waste of money.

Because people are so complicated biologically, psychologically, and socially, I think a far better way for docs to decide which meds to use is to use pattern recognition: Doing a wide-ranging diagnostic evaluation and looking at what factors suggest certain courses of action.

Let’s start with the diagnosis of major depressive disorder. That diagnosis has to be based on a variety of considerations. Symptoms must be pervasive (almost all day every single day, even if you suddenly win the lottery. I exaggerate, but only slightly) and persistent (at least two straight weeks), and the patient’s functioning and stress responses must be significantly different that their norm. (Antidepressants do not work on chronic unhappiness). All symptoms must take place at the same time – having no appetite on Monday and poor sleep on Thursday does not cut it.

If it’s a patient’s first episode, another big issue is that there is no way for the doc to be absolutely certain that it is not a first episode of bipolar disorder rather than a unipolar depression. This is important because if the doc prescribes an antidepressant to a bipolar patient, it can trigger a manic episode – with disastrous consequences. So what is a doctor to do to make sure that doesn’t happen?

Family history is important, since bipolar disorder usually runs in families. If a patient has a family history, the doctor has to be more careful. The problem is of course that the patient might not know if he or she even has a relative who had a manic episode. So what does a good doctor do? In addition to asking about family history, the doc should carefully review the patient’s history for any symptoms suggestive of the disorder. These symptoms should not have occurred only when the patient was high on cocaine, or during a rage reaction upon having found out that the their spouse and best friend were having an affair!

Next, the doc warns the patient about the bipolar issue, and informs patients that in the event of suddenly feeling revved up, they need to STOP the antidepressant and call the office immediately. This instruction can be given at the same time as the doctor describes all possible major side effects with instructions on what to do should they occur. Then, the doctor needs to have the patient comeback for a scheduled follow up visit, preferably within two weeks.

Now, about picking an antidepressant with which to initiate treatment. As I mention, genetic testing is not particularly valuable. It’s always a bit of a crap shoot because a patient’s presentation may be somewhat atypical, but if the doc takes a complete history, it can suggest which agent to try first. If the patient has some obsessive-compulsive qualities, an SSRI like fluoxetine  or escitalopram is a good first choice. If in addition to that there is a lot of anxiety, the SSRI paroxetine is usually the best choice. If the patient has chronic pain, then duloxetine is usually a good starting point. If sexual side effects are a big concern, buproprion is usually the place to start.

Next, the doctor raises the dose of the medication every three to four weeks until there is a response, or it reaches the maximum dose, or until side effects become too big a problem. At this juncture, the doctor should NOT add another, different class of medicine to “augment” the antidepressant, as is suggested by a lot of Pharma commercials. If there has not been a good response to the first drug, the anti-depressant should be stopped, and a trial of a second antidepressant should come next. And again, if no response, a third one. There are diminishing returns here but eventually most patients will have a decent response. If they do not, then than and only then should an augmentation strategy be instituted. Or the diagnosis may need to be re-evaluated.

Close follow up. Close follow up. Close follow up.

My Blog on Feedspot's Top 100 Psychology Blogs

 

Family Dysfunction and Mental Health Blog has been selected by Feedspot's panelist as one of the Top 100 Psychology Blogs on the web.

https://psychology.feedspot.com/psychology_blogs/

Are Effects on Brain Development Due to Psychological Trauma in Childhood Permanent?

 

Romanian children who had been stuck in orphanages in which they had almost no direct interactions with their caretakers had been studied extensively by a group of researchers, as described in the book Romania’s Abandoned Children: Deprivation, Brain Development, and the Struggle for Recovery  by Charles A. Nelson, Charles H. Zeanah, and Nathan Fox.

Generally, the longer these children were in the orphanages, and the earlier they got there, the more damage to their cognitive abilities, social skills, and stress tolerance there was later in childhood after they were adopted by foster families. Some of them even showed reduced circumferences of their skulls. Hard to imagine that was not permanent damage. Most affected children did seem to show some recovery in their development after adoption, but did not seem to get back completely to normal. 

They were not followed much past adolescence in the original study. However,  according to a follow-up study described by the BBC, many of these young children adopted by UK families in the early 90s are still experiencing mental health problems even in adulthood (https://www.bbc.com/news/health-39055704).

Despite being brought up by caring new families, this newer long-term study of 165 Romanian orphans found emotional and social problems were commonplace. Initially, all 165 had struggled with developmental delays and malnourishment. While many who spent less than six months in an institution showed remarkable signs of recovery by the age of five or six, children who had spent longer periods in orphanages had far higher rates of social, emotional and cognitive problems during their lives. 

Common issues included difficulty engaging with other people, forming relationships, and problems with concentration and attention levels which continued into adulthood. This group was also three to four times more likely to experience emotional problems as adults, with more than 40% having had contact with mental health services. Despite their low IQs returning to normal levels over time, they had higher rates of unemployment than other adopted children from the UK and Romania.

Interestingly, one in five of them seemed to have been unaffected by the neglect they experienced. A small percentage, to be sure, but if the types of experiences these children had cause permanent brain damage, how is this even possible?

In current literature about the effects on the brain of trauma, the common opinion expressed by experts is that they are irreversible. Brain changes that are seen in various neurological evaluative procedures - such as different brain scans - do not seem to go away.

I, on the other hand, have theorized that the effects of trauma on the brain may be reinforced by continued interactions with primary attachment figures, whether they be natural or adoptive parents. If this is going on, the brain changes would not go away. Neural plastic changes leading to this would not happen.

But, people may say, many of these traumatized Romanian orphans were adopted into loving families! If what I believe may be true actually is true, why do scars remain in 80% of these orphans?

Answering this question definitively is extremely difficult to do. Surely, due to variations in the genetics of the orphans, some may have been more vulnerable to permanent brain damage than others. I mean, smaller skulls? But again, on average, and not in all of them. Also, the experiences of the orphans in the orphanage probably varied significantly, with a few of them possibly exposed to more helpful caretakers than the others.

What is rarely discussed is how difficult it is to raise children who have been traumatized in the way the orphans had been. They were difficult children with huge behavior problems, and how to provide proper boundaries in a loving manner is something that many parents of very normal children have difficulty doing. No matter how well intentioned the parents may be. Some of these parents might get help from knowledgeable family therapists, but most do not. So in some ways, the children may be continuously further traumatized by angry and frustrated parents who don’t have a clue as to how to best interact with them.

In the original study, there was some preliminary evidence that interventions by therapists with the adoptive parents were helpful, but such interventions did not usually take place. Even when they did, the quality of therapy the parents receive could vary widely.

So addressing the family dynamics of these adoptive families of adult survivors of the Romanian orphanage, so that these behavioral and cognitive deficits are no longer being triggered and reinforced, might possibly lead in many cases to a reversal of both the psychological deficits as well as the brain changes caused by the original trauma.

I like to think so.

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.

Willpower, Groupthink, and the Disease Model for Everything

Columbine School Shooting, public domain 

When addicts say, "I can quit using any time I want to," people usually laugh at them and accuse them of being "in denial." I, on the other hand, believe they are telling the truth. Since they are admitting they don't want to quit, they aren't denying anything. Of course, the big question is why they don't want to quit. It can't be because the substance is making them feel good. They are generally some of the most miserable and unhappy people around.

So maybe they have some genetic defect that causes a “disease” that impairs their self control? While it is true that genetic tendencies can make someone a bit more or less likely to engage in certain behaviors, the majority of these effects are relatively small. 

If genes were causing the problem, one wonders how 12 Step Programs, which are based on religious conversion techniques that demonize people’s ability to make good choices for themselves and ask people to surrender to group norms and do what they are told, would ever succeed. Last I heard, changing your religion does not lead to major changes in one’s genome. Or its physiological effects.

I suspect the group’s views and where their ideas come from have something to do with the addict’s problems. Before they quit, they are proving the group’s opinions about the evils of willfulness, and after they quit they are proving the group’s belief system once again, but in a different way.

And is it really true that they can’t control their urges? Does an alcoholic actively engaged in drinking and driving usually take a big swig of Jack Daniels just when a cop pulls up in the lane next to them? Well, I suppose some might, but I suspect that such individuals are again going out of their way to prove their group’s idea that their willfulness is creating their problems. But most will keep the bottle hidden. So I guess they can control their urges even while intoxicated with their favorite beverage.

And of course, as I have previously pointed out, animal models of alcoholism are generally poor because scientists can’t seem to find any rats that hide the bottles. And the bottles that people hide are almost always found eventually. Usually  by spouses and family members. Imagine that.

Another point: Non-academic people in the addiction discussion also talk a lot about how co-dependency and enabling spouses and relatives are part of the problem in someone’s addiction (see Al-Anon), but somehow today’s scientists seem to think these other folks have nothing to do with the addict's problems. Really?? In what alternate universe?

I find it impressive how today’s psychology academics seem to go to any extent to avoid looking at dysfunctional family dynamics as a major cause of behavior that is destructive to one’s self or others. For another example, look at speculation about the causes of the recent spike in students committing mass shootings at schools. If the role of the parents is looked at at all, it seems that their only role is giving their kids access to weapons and ignoring danger signs, but not in creating the environment conducive to motivating their children to act that way in the first place.

Now of course having access to assault weapon is a prerequisite for committing these crimes, but what about the literally millions of homes in the United States in which such guns are found? If the presence of guns were the only problem, these shootings would have been going on at the current frequency for the past decades and decades.  For a similar reason, even overt child abuse alone cannot explain the shootings, as the vast majority of abused children do no such things. There has to be other things going on in these families. What, for example, are the parents saying to these kids and to each other, and how are they reacting in general to kids who start to have fantasies of violence? 

One of the Columbine shooters in the above picture literally collected an arsenal of weapons in his house prior to the act. When interviewed by the press, his mother said she didn't know about it. I wonder how the shooter interpreted the fact that his mother apparently pretended to not even notice the obvious.

No one seems to be asking these essential questions. Sad.

Pathological Narcissism and Pathological Altruism: Two Sides of the Same Coin

 

 “A good life balances our own self-interests with other people’s needs…Healthy narcissism is where passion and compassion merge, offering a truly exhilarating life.” ~  Craig Malkin

Balance in life. Lately, that seems like an unknown concept in our black-and-white, all-or-none thinking times. 

In his book, Rethinking Narcissism, Dr. Malkin distinguishes healthy versus unhealthy narcissism, the latter being characterized by the (dictionary) definition of excessive interests in one’s own importance and abilities. (In fact, as a described in a previous post, its base [in Narcissistic Personality Disorder] is often a subconscious sense of inferiority combined with a sense of not being appreciated by others).

On the other hand, caring for others at one’s own expense also has healthy and unhealthy versions. I’ve also written about, using Barbara Oakley’s term, pathological altruism - in which one’s sacrifices not only lead to misery or deprivation for the giver but also backfire and lead to harms for its objects.

Although it’s a bit of an oversimplification, I also illustrated it with something I called the Mother Teresa Paradox: if she’s right and giving to others is life’s greatest reward, then by not allowing others to give anything to her, she is in effect depriving everyone else of what she herself defines as the best life has to offer. 

A common example in our culture is: the whore/Madonna complex, in which even married folks feel they are evil if they enjoy sex too much with one another. Especially women. Men at times and in certain social circles have been allowed to enjoy it with non-spouses, who are nonetheless derided as whores, because of a need by their group for them to have sins to atone for on Sundays.

I believe, and my Unified Therapy psychotherapy paradigm is based on this, is that this sort of craziness is a result of the evolution of individuality out of collectivism over the last three centuries, as described in the marvelous book Escape from Freedom by Eric Fromm. Sometimes it’s best (and was especially in the past) for the survival of our species if under many circumstances we sacrifice ourselves for the tribe. But that has become increasing less necessary and even counterproductive as science and technology have taken center stage. Nonetheless, we are still primed by our genes to do it (due to kin selection), but it is becoming more and more counterproductive. 

Our own family interactions sometimes don’t keep up with changing environmental contingencies, leading to something called cultural lag, which leaves families confused and conflicted over which standards to follow in this regard.

This in turn can lead parents to give destructive mixed messages to their children. We do have the power to use our critical thinking skills to get everything back into a healthy balance, but are often severely invalidated by our own families whenever we try, leading to a horrible sense of not knowing who we are or what we are supposed to do any more (called anomie or groundlessness).

In situations in which a whole family is conflicted over some issue, this is often indicated when people behave compulsively in one extreme way or in the opposite extreme way, or bounce back and forth between the two extremes.

Problems like these have to be discussed if they are to be solved, but people are often too ashamed or defensive to do so. The countermeasure is empathy, which comes from doing research into one’s family background in order to understand why our parents are driving us crazy. How to employ this is described in both my psychotherapy paradigm for self-destructive behavior (which by definition cannot be selfish unless an individual is nearly brainless) and in my self-help book for somewhat more functional families.

It was really impressive when my patients had an “a-ha” moment that led to the reaction of “So THAT’S why they act that way!" It was very liberating for them, although that freedom can still easily be undone by aggressively invalidating family attachment figures. I teach strategies for getting the parents to stop doing that.

If you are in a cycle of self-destructive behavior, such as, say continually going back to an abusive marriage because your parents seem to be blaming you for it (and if you have been going back, it is not “blaming the victim” to say that you bear some responsibility for your own plight), my message to you is to learn about this stuff and how it has affected you personally and your family, and to take charge.

Bad Child Psychology in Schools – How to Make Kids Feel like a Big Burden to Resentful Parents

 

Why aren’t many kids seemingly growing up as maturely as they used to any more? Why are mental health problems and suicidal ideation as well as actually suicides increasing? Why are more and more children losing self confidence and feeling defective? 

In a new book by Abigail Shrier, Bad Therapy: Why the Kids Aren’t Growing up, the author blames the mental health establishment. So does the parenting guru I’ve been reading for years, John Rosemond. And psychologists are indeed a big part of the problem. But both miss an important aspect of the phenomenon.

 

The definition of “traumatized” in children has been expanded beyond all recognition by the profession. In the mental health field, consideration of the effects of adverse childhood experiences have gone back and forth from one extreme to the other: the serious ones at times are almost completely ignored. At other times child abuse was thought to be everywhere. And now trauma is seen as almost any occurrence that makes a kid in the least bit unhappy or stressed. 

I described what has been going on at the college level in my review of the book, The Coddling of the American Mind, with students' reactions to “microaggressions,” and political incorrectnesss being equated with PTSD caused by a terrifying combat experience. 

Nowadays, according to Shrier, kids are seen as being unable to put aside even hurt feelings in order to concentrate on the school work in front of them. Resilience is now seen as “accepting” these “traumas” rather than dealing with them in a potent manner. Personal agency has seemed to have “snuck out the back door.”

 

And 40% of the current, rising generation has received psych treatment versus 26% of gen-X’ers when they were younger. More and more phony psych diagnoses are put on kids, often at the suggestion of teachers. More and more children are afraid to be wrong in school laboratories or to test new ideas for fear of making a mistake. Bullies are being suspended less and less frequently for fear of damaging their self esteem. American children are more likely than others to exaggerate all kinds of risks.

 

For those mental health professionals who do recognize all this as a problem, the usual explanation for why it is happening is that when parents and teachers over-protect and over-pathologize their children, they are preventing them from learning social skills which, it is believed, cannot be “taught” in most cases but must be learned through trial and error. 

If a parent always steps in, or even when parents don’t let their children go out to play or walk to school because they believe that something bad will happen to them, the kids are said to never get the chance to learn those things. As the author also points out, sometimes feeling mildly to moderately anxious or moody can be a good thing since it can motivate kids to evaluate their situation and lead them to take action.

 

Now don’t get me wrong. There is much truth to these assertions. What’s missing, however, is the way this sort of treatment by parents and teachers is interpreted by the children themselves. The children start to see themselves as a big burden to their over-anxious, worrying parents. Not only that, but the parents seem angry about it. I believe that if a child feels like too big a burden to their parents, they may start to think their parents would be better off without them. This could increase their risk of suicide.

 

Why? Because, as I have been arguing for years, children are willing to sacrifice their own best interests in order to stabilize their parents. This is due to the evolutionary force called kin selection. It is not just that kids don’t experiment with new behavior in order to figure out how to, say, respond to a bully. Hell, there are TV shows, YouTube channels, and many other sources for suggestions that they could try out at school. But as long as they feel the need to let their parents take care of them, they are not motivated to become independent. "Enabling" parents lead to co-dependent children.

 

Schrier does allude to this aspect of the process involved here, but it is not clear to me that she truly appreciates the extent of the issue. She does say that kids often feel responsible for their parents, and may feel like a “constant burden to their stricken parents.” She also says that there is nothing scarier to them than parents “overmatched and afraid.” She has also noticed that people who make parenting look exhausting do not seem all that fond of the kids they raised. If an untrained observer like the author can see this, then guess what? So can the children. And they will be induced to make any necessary sacrifice.

Intergenerational Transfer of Trauma: The Unrecognized but Essential Mechanism

In my last post about the internal family systems therapy model, I discussed how some newer models (ones that come close to my own) seem to completely ignore the ongoing nature of repetitive dysfunctional family behavior even after the children grow up. Or as the book It Didn't Start with You by Mark Wolynn sometimes does, what happens with an adult child’s interactions with parents in the present.

I have championed the idea of the intergenerational transfer of dysfunctional family “rules” that are due to a previous group or individual trauma. I am very happy to report that this subject seems to finally be getting the attention it deserves. In my very first book, originally released way back in 1988, I proposed very specific mechanisms through which this occurs. 

While there is a genetic component to this such as changes in the body's stress response reactions (e.g., release of cortisol), why do we think these have to be permanent? If they were, then treatment or therapy would do precious little.

Perhaps the reason they do not change is that they are continually reinforced in the present. Neural plasticity tells us that brain circuits are strengthened or weakened depending on how much stimulation they get, and relevant interactions with parents do not stop at age 18, or even at age 3-5 as  some analysts used to think. Especially since the circuits are created and then reinforced (or not reinforced) by attachment interactions in the first place.

The subtitle of the book under review here is How Inherited Family Trauma Shapes Who We Are and How to End the Cycle. The author mentions that in many many cases traumatized parents and grandparents avoid talking about what happened to them, mostly out of shame. I completely agree. However, that does not mean that there is nothing that can be communicated through a variety of other behaviors in ongoing interactions.

Wolynn gets ever so close to understanding what’s going on, but is IMO missing the continuous drama. When he notices that sometimes parents have not discussed the trauma, he in fact does wonder how then the trauma might be passed down. He over-emphasizes genetics.

It is true that if a mother were traumatized, that can affect how she interacts with a kid, which can itself be traumatizing. This can lead to epigenetic changes (genes being turned off and on) in the child that affects their reactivity and perhaps their proneness to certain medical and psychiatric disorders. But that’s as far as it goes. He mentions that epigenetic changes occur mostly through a chemical process called methylation, but seems to think they are not reversible. If a gene that regulates other genes can be methylated, it can be unmethylated.

He gives an example of a boy named Jessie who at the age of 19 suddenly developed severe insomnia accompanied by freezing, shivering and an inability to keep warm. He had no major problems sleeping before this. He had to drop out of college because of these symptoms. Doctors could find nothing wrong. Jessie later revealed to Schwartz that he had only recently became aware of the fact than an uncle he never knew he had froze to death – at the age of 19. 

So does this mean that this was some sort of genetic effect? Even the author seemed bit skeptical. Let’s face it: genes do not and cannot contain specific memories like dates when traumas occur. Maybe the father, whose brother it was, started acting strangely in some way when his son reached that age.

Wolynn also falls for an aspect of the heritability fraud when he agrees that all children grow up in the same family, so this must be a “shared” environment. But somehow he is also aware of the Murray Bowenesque understanding that parents can relate to each of their children much differently than to the others for a variety of reasons. This is especially common in so-called dysfunctional families.

Not to mention the fact that siblings can all be affected by the family trauma in very different ways despite the specific nature of the mother’s traumas and any resultant internal conflicts. And some of children may not affected much at all. He never addresses the clear contradiction in these ideas. What distinguishes those who do from those who don’t? Are their genomes that different? 

Another thing that Wolynn does not seem to be aware of is similar to the lack of understanding by Richard Schwartz in internal family systems therapy that I described in my last post. He does not quite seem to get that a lot of the people he writes about are not protecting themselves, but are in fact self-destructive. The case of “Elizabeth” on page 205 illustrates this clearly. According to the author, she felt rejected by her mother and so feared that everyone else was going to reject her. She would then feel left out and all alone.

But her response to this? Isolating herself. Left out and all alone. The very thing she claimed to fear! At her job she almost completely separated herself from co-workers and would barely talk to anyone all day.  She was not described as being anywhere near stupid enough to not see the rather obvious results of what she was doing.

In this case as a therapist, I would ask a modified version of the Adlerian question to find out who she was sacrificing herself for: If I had a magic wand and could make you accepted and popular, and prevented you from screwing that up, who might be negatively affected?