Saturday, April 30, 2011

How to Disarm a Borderline, Part VII: Suicide Threats

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29), Part III (November 24), Part IV (December 8), and Part V (January 12), and Part VI (March 2). The countermeasures described in this post do not work in isolation but must be part of a complex, consistent, and ongoing strategy.

In this post, I will discuss the most dangerous and difficult problem of all, suicide and parasuicidal behavior. Parasuicidality includes suicide attempts, gestures, threats and non-suicidal self-injurious behavior (SIB) such as cutting or burning oneself.  In my opinion, self-induced vomiting and drug or alcohol binging are also SIB.  In some cases, also in my opinion, excessive body piercing and tatooing may also be.

***Important caveat:  In cases in which a family member engages in suicidal or parasuicidal behavior, strong efforts should be made to get that person to a mental health professional who has experience with, or even specializes in, borderline personality disorder.  No one should attempt to deal with such a person all by themselves.  However, getting an oppositional individual to seek help is often in itself no simple feat.

Having said that, I can still discuss some things that are helpful for anyone dealing with such a person to know.

First of all, it is important to be aware that just because a person has make a lot of idle suicide threats in the past, this does not mean that they will not kill themselves in the future.  Follow-up studies have shown that individuals with BPD have a 10% rate of completed suicides over the long term.  That is nothing to sneeze at.  Of course, that means that the good news is that about 90% of persons with BPD will not kill themselves.

So one does have to take suicide threats seriously.  On the other hand, if a relative goes into hypercontrol mode every time a person talks about suicide, and tries over and over again to get the person committed to a mental hospital, this may actually make things worse rather than better. Remember, making others feel helpless is part of what persons with BPD try hard to do, while secretly hoping that they fail at it.

There is no evidence that psychiatric hospitalizations reduce the long term risk of suicide in patients with BPD.  Hospitalization should only be used occasionally to buy time during an unusual acute crisis so that the unusual circumstances pass.  This may reduce an imminent risk. 

Furthermore, individuals with BPD can use parasuicidal behavior to make others look foolish.

I learned this the hard way.  When I first started practicing in the late 1970's, a time when BPD was far less prevalent than it is today - it wasn't even in the DSM until 1980 - I was providing back up coverage for another psychiatrist.  I got a call from one of his patients. 

The woman immediately started making wild suicide threats.  I found out where she was at and called the police to go out to her house.  By the time they got there, she was calmly knitting away like Madame DeFarge and sweetly telling the police, "I don't know what Dr. Allen is so excited about; I never said anything about killing myself."

So what else should a lay person know that might be helpful in negotiating this minefield?
First of all, if an individual with BPD says that they are thinking about suicide, this is usually not a suicide threat.  People with BPD frequently think about suicide.  Doing so is actually one of the criteria for the condition.  If, on the other hand, the patient says, "I am going to kill myself," then the threat should be taken more seriously.
Second, if a person is dead set on killing himself, pardon the pun, then there is literally nothing you can do about it. You are helpless.  As mentioned, hospitalizations can only buy time.  We cannot lock such people in a hospital room and throw away the key.  They will be out eventually.  Fortunately, most individuals with BPD are highly ambivalent about dying.
Third, most SIB is not meant to lead to death.  People hurt themselves because it makes them feel better when they are overwhelmed and highly anxious, not because they wish to die.  "Pulling your hair out" is a common expression concerning this feeling, so the urge is not exactly unknown to non-BPD individuals.  Otherwise normal people often slap themselves in the head or pound their fist into a wall when frustrated.  So, while witnessing or hearing about a loved one engaging in SIB is very distressing, one usually does not have to worry about actual suicide.
Suicide gestures are usually impulsive, non-lethal reactions to an episode of an interpersonal conflict that are meant to manipulate the other person, and likewise do not often lead to death.  People in this situation will cut their wrists or take a handful of pills that they know will not kill them.  Obviously, if a person takes a handful of pills one should probably call 911 anyway.  Sometimes suicide gestures accidentally lead to death.  One can choke to death on the pills, for example.  Several rock stars apparently met their demise in this fashion.
Another important clue as to the seriousness of a suicide threat is the tone of voice and the choice of words made by the threatener.  If someone says that they may kill themselves at some point and are being coy about exactly when and where, that usually means that they are not imminently suicidal but are trying to make you feel helpless.  Another clue is when their tone sounds something like, "Nyah, Nyah, Nyah - Nyah, Nyah, I'm going to kill myself and there's nothing you can do about it." The threat may not be a serious one.
For example, the very first patient with BPD I saw as a resident, which coincidentally was the first patient I ever had in psychotherapy, started making such threats.  We were in an outpatient office late on a Friday afternoon.  I picked up the phone to call security.  She calmly reacted with, "You know if you call security, I'll run out of the room and I'll be gone before they get here."  Zing, she had me.  I was in a total panic as she indeed quickly left the office.

In the cell phone age, things are even worse.  Threateners can phone in a suicide threat, knowing that there is no way they can even be located. 
I spoke to a faculty member about the patient I just mentioned.  He suggested I could have said, "You really want me to worry about you, don't you?" 

Had she then replied, "Oh, bull! You don't care about me," I could have replied, "Well, I am going to be worried about you all weekend."  Good advice.

I could have also said, in a sincere tone, "I sure hope you don't do that."

By the way, that patient showed up on time for our next regularly scheduled visit as if nothing had happened.

I do have one other intervention I frequently use called the paradoxical offer to hospitalize.  It's paradoxical because it is meant to keep people out of the hospital.  It is not really appropriate for a lay person to use, so I won't describe it here (Therapists can find it in my book, Psychotherapy with Borderline Patients: An Integrated Approach).  Besides, I don't want potential patients to know all of my secrets.

Monday, April 25, 2011

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.

Friday, April 22, 2011

PsycCritiques Review of "How Dysfunctional Families Spur Mental Disorders"

My book was recently reviewed in the American Psychological Association's main book review journal, PsycCritiques.  The reviewer didn't like the book's title as he felt it did not accurately reflect the contents.  I hate coming up with titles for books! 

Anyway, the reviewer, family psychologist Dr. Scott K. Shimabukuro, liked what was inside the book.  The whole review is only available for a price, but here are some excerpts:

"It is not that this book does not discuss how family dysfunction relates to mental disorders, but rather that it also spends a considerable amount of time on other more distantly related topics such as Big Pharma propaganda or biased research and publications, Reaganomics and mental health, the nature versus nurture debate, managed care, neurology, evolutionary theory, what evidence-based treatments really are, how the women’s movement affected families, and differing schools of psychotherapy, along with the topic of families and their relationship to a family member with a disorder...

"...A moderately well-read professional in the field will be more than familiar with the majority of the material presented here but would certainly not have seen it within the covers of a single book. Lay readers will be glued to the pages as Allen takes them on a journey that spans the molecules of neurotransmitters to the belief system of eugenics in the United States and Germany. Somewhat reminiscent of books like Freakonomics that cover a wide range of topic areas that revolve loosely around a theme, Allen’s book uses family dysfunction as a vehicle on which many other interesting commentaries can ride. And this is where the book gets fun...

"...Allen never forgets that there is no simple answer, and therefore readers not comfortable with the gradations of gray will be unsatisfied. In the real world, biology changes the environment, and the environment changes biology; therefore, any simple biology-plus-environment arithmetic does not suffice—a fact that Allen does not forget. The book goes on to discuss the related issue of whom to blame, if anyone at all, when a family member has a mental disorder.

"...If, however, I consider it as an exposé of the field for general public consumption, I would highly recommend it. It pulls the curtain back from the world of psychotherapy, psychopharmacology, and more. It is an informative and entertaining collection of the many facets of the field. I know that from time to time, I will be pulling this book back off the shelf to peruse a favorite chapter or two."

Monday, April 18, 2011

Putting an End to the Game Without End

In my post of November 18, Changing the Rules of a Game That Will Not End, I described what I find to be a fascinating phenomenon that seems to take place whenever a family member attempts to change the existing rules by which the family operates.  Because everyone had compulsively followed the rules before that point, no one really believes anyone else really wants the rules to change.  That happens even when everyone in the family would be happier with the rule changes than with the previous set of rules.

What happens next is that people start doing the new, requested behavior, but they do it in a half-baked or obnoxious way.  When the person who requested the change then complains about the new behavior, everyone else thinks to themselves, "See, I just knew they really did not want the change in the first place."

In the earlier post, I gave an example concerning attempts to change traditional gender roles that a lot of folks may be familiar with.  When both a husband and wife have to work, the wife often still ends up doing the bulk of the housework and childcare. Why? Is it because men are all male chauvinist pigs?  Well, no. 

In this situation, the husband will generally start to do, say, the after-dinner clean up, but purposely does a poor job, puts things away where the wife can't find them when she needs them, or does things in some other way that he knows the wife will find objectionable. 

She then almost invariably complains to him that he's not doing it right, and he concludes that she really does not want to cede control of the kitchen despite her protestations to the contrary.  So he stops doing things unless she specifically asks him to do it.  She gets tired of always having to ask and then ends up doing everything herself.

In a way, she is often not completely comfortable ceding control of the kitchen- but only because she may have been taught in her own family of origin that the housework was a woman's job. 

Conversely, if she is asked to take over a traditionally male job such as taking the family car in to get fixed, she will do a very similar thing to him.  She will draw criticism about the way she goes about it (often with the help of an unscrupulous auto mechanic, who believes that he can cheat her because he knows that she probably does not know very much about cars). 

Hubby then gets mad that she spent too much or got cheated, and she concludes that he really wants to remain in charge of things like that.  Which he sort of does, since he had been taught in his family of origin that getting cars fixed was the man's job.

People in a family system will almost invariably "test" any new, requested rule change in this manner.  They do it this way in order to give the person who is requesting the rule an "out" - just in case he or she really is uncomfortable with the change. Through their actions, they also take the blame themselves for any failure to change the rules.  Family members are so generous that way.

At the end of the previous post, I mentioned that there is relatively simple way for game players to end the game without end, but that I would save that for a later post. This is now that post.

In order for this solution to work, it is important for individuals requesting the change to freely admit that they are not completely comfortable with the changes, but only because they were raised to follow the old set of rules.  They now see the error of the former ways, but it will take some time before they get comfortable with the changes.

When another family member then does the requested behavior in a half-baked or obnoxious way, the person requesting the change should first praise the person for trying to do what was asked for.  Then and only then should the requester quibble with the way that the task was performed. 

For example, "Thanks for doing the dishes, honey, I really appreciate it.  But if you are going to move things around, please tell me so I know where everything is."

Another example from the previous post: a wife had been encouraging her husband to be more honest about his true feelings and not so closed off. Consequently, he began to express himself, but in an abrasive fashion in front of her boss.  The wife here should wait until she is no longer furious with the husband for doing that, and then say, "I'm really glad that you're being more open about your feelings, but I really wish you wouldn't do that in front of my boss."

Point, game, match.

Wednesday, April 13, 2011

Ve Have Vays of Making You Talk, Part I

Oh, how family members hate to discuss chronic repetitive ongoing interpersonal difficulties with each other.  Everyone fears that they will hear something about themselves that is negative.  Some do not want to face up to or admit to anything they may have done wrong. 

If they are already feeling guilty about their past behavior, they may expect they will be unjustly blamed or misunderstood or humiliated.  Sometimes discussions about family dynamics, also called metacommunication, elicit anger or lead to an emotional cut off or the silent treatment. Some may even lead to violence.

All this may be true. However, an even bigger factor in many folks' reluctance to metacommunicate is often that family members worry that their thoughts and feelings about the other person will hurt the other person's feelings.  They fear that the Other cannot handle the truth because of intrinsic weaknesses,or that the truth might lead perhaps an exacerbation of his or her tendency to drink too much or even to become suicidal.

This reason for avoiding saying what you believe in order to avoid hurting others is part of what I refer to as the protection racket.

On the other hand, a family member might worry that a flat refusal to discuss a problem when pressed by another family member may seem rude or inconsiderate.  So in response people have developed a whole repertoire of behaviors to very subtly get out of such discussions without appearing to be completely uncooperative. 

Some of these strategies can be so subtle that the other person often does not even realize that the discussion has been completely redirected toward a more benign-sounding subject than the one the original complainer had in mind.

Another important aspect of this is that the original complainers may dread such discussions themselves.  They may have spent weeks building up the nerve to bring up the complaint, and are subconsciously relieved when the discussion is derailed.  They therefore cooperate with the ruse.  To prevent this from happening, those bringing up a problem for discussion have to remind themselves that, despite their discomfort, the problem really needs to be effectively and directly addressed.

In Part I of this post, I will discuss the most common of avoidance strategies - merely changing the subject - as well as suggest effective countermoves to keep a conversation on track.  The goal is effective and empathic problem solving.  In future posts I will do the same for other such strategies. 

In all counter-strategies, maintaining empathy for the Other and persistence are key.  

Strategy #1:  Changing the subject.  The person avoids a touchy issue by diverting the conversation to something else.  This one seems pretty straightforward and simple to understand, but often it is more difficult to spot than one might think.  Subject changes can be both subtle and insidious. 

For example, a person may go off on an interesting tangent.  A discussion that starts with someone bringing up a marital problem concerning the spending habits of the other person, for instance, may be led astray when the the Other discusses one particular recent but somewhat atypical purchase and how important it was to the couple.

This may then lead to fun stories about events that transpired over the object in question during the entire relationship.  The original complainer starts to reminisce with the partner, not even realizing that the original complaint was completely deep sixed.

Other examples are when the Other make jokes, or looks for something in the environment that seems to need attention right away and suddenly starts talking about that after a nifty segue.

The first thing one has to do to counter subtle misdirection is to realize when it occurs, and then bring the subject back to where it needs to be.  The complainer's first countermove should be to directly change the subject right back to the original issue. 

If that fails, the complainers should then point out in a non-condemning manner how the other is avoiding their concerns and insist on returning to the subject at hand.  If the other still persists in sidetracking maneuvers, the complainers should step back and ask themselves why the Other is becoming uncomfortable, and then either empathize with his or her concerns, or if they cannot find a way to do that, express puzzlement over the Other's reactions. 

Another way to derail a conversation through a subject change is through the use of a counter-complaint.  The original complaint is not addressed, but instead the Others brings up a complaint of their own.  This maneuver usually takes the form of a statement beginning with, "Well you..." or "What about the time that you...?" The original complainant is then cowed into discontinuing his or her effort to address the original issue.

There are two versions of this strategy, each requiring very different counter-moves. The first is when the Other brings up a complaint that is completely unrelated to the original complaint.  In this case, the person should reply, "Well, that's an important issue for us, and I will be happy to discuss that with you later, but first I think we need to come to some mutually agreeable understanding on what I am bringing up."  One has to be willing to non-defensively do just that later on, of course, or else this strategy will eventually fall flat.

In the second version, the Other says something to the effect that, "Well, you do the same thing that I do (so how dare you complain about me)."  It is usually not stated this clearly, however.  The Other instead may bring up a specific example of the problematic behavior as practiced by the original complainer.  For instance, if an adult child wants to talk to a mother about why the mother stayed with an abusive spouse, the mother will start talking about the complainer's relationship with his or her own abusive spouse.

This type of response usually leads to defensiveness on the part of the original complainer, which then leads to an argument instead of effective problem solving.  An effective countermove is to acknowledge the legitimacy of the comparison, if it is in fact legitimate. 

Although there may be important differences between the behavior of the mother and the child, usually there are significant similarities as well.  The complainer should ignore the differences for the time being and say something like, "I was not trying to rake you over the coals for staying with Dad.  Isn't it interesting that we both seem to have the same problem?"

This turns the conversation into a far less provocative conversation about about a mutual difficulty.  It is far more difficult for the Other to feel criticized by the complainant if the complainants admit to having the same problem themselves.

Yet another way to change the subject is to make it a bit confusing as to what the subject actually is.

Ambigous language might be used by the Other so that the first person is not sure if they are both talking about exactly the same thing.  For instance, an adult mother of a teenager and the mother's own father were discussing how the grandfather was only willing to help with his grandson's expenses when he was living with his father, but not when he was living with the complainant. 

The woman was a single working mother with significant financial hardships.  Mixed in with this subject were allusions to the father's somewhat similar behavior when the mother was herself a child.

After a while, it became very difficult to tell which of these subjects was being discussed at any given time.  Were the mother and her father talking about themselves, or about the grandson?  Most of the references made within the conversation could apply to either one.

Again, spotting the confusion through understanding the analogies is the first step in separating out the ambiguous references so that the pair can discuss a single pattern (that probably started when the mother was a child and is continuing in an altered form in their current relationship whenever the needs of the grandson arise).

A related misdirection strategy is to mix several separate but highly interconnected issues so that none of them is ever completely discussed. For example, one woman was in a complex family system in which her husband would distract her from her anger at her parents and vice versa.  The husband and the mother would both do things to get the patient angry to draw her anger towards them. 

The genogram revealed that the problems in the system were related to gender issues (whether men should take care of women or women should pursue independence), concerns re the adequacy of males in the family (her husband felt that he was supposed to protect his wife but felt inadequate to do so and angry about "having" to shoulder the responsibility) and even class (how much money was being brought in and whether wealthy people are shallow).

The discussion would change from one of these aspects to another at the drop of a hat.  Because the aspects were all so interconnected it was indeed difficult to talk about one without talking about the others (for examply, when the issue of the husband's adequacy came up, the issue of why he was like that would also arise).  Because the subject jumped around, however, any conversations about the issue would end up going in circles with nothing being resolved.

In some relationships, large numbers of related issues are brought up in a sequence.  By the time the pair gets done with the last one, the arguments about the first one have already been forgotten, and the sequence begins all over again.  It repeats ad nauseum.

Again, the most important countermaneuver in these situations is to recognize what is happening.  The original complainant should then bring up the fact that there are several related issues, acknowledge that dividing them up is somewhat artificial because they are so intertwined, but request that they do so anyway before going off on a tangent. 

If that does not work, then once again the complainants should follow the steps discussed earlier in this post: first point out in a non-condemning manner how the other is avoiding a subject and insist on returning to the subject at hand.  If nothing changes, the complainers should next step back and ask themselves why the Other is becoming uncomfortable, and then either empathize with his or her concerns or express puzzlement over the Other's reactions.

Friday, April 8, 2011

Why Don't They Tell?

One of the things that child abuse deniers like the False Memory Syndrome Foundation focus on, besides Elizabeth Loftus's irrelevant arguments about the unreliability of memory, is the fact that many adults who claim to have been victims of incest as children did not tell any other adults about it at the time the alleged incidents took place. 

John and Mackenzie Phillips

Some children do tell.  So why wouldn't the others?

A whole bunch of logical explanations have been advanced to explain why not. In an article in the December 2010 issue of Psychiatric Times, Richard Kluft lists several of them:  incomprehension, shame, fear of retaliation, and the misperception that the child is to blame.  He also mentions loyalty conflicts, but more on that in a little bit.

The statistics listed in this article, as unreliable as they may be, say that only 30% of incest victims reveal their situations, and most of the revealers are the older children and adolescents.  In almost half of these, the revelation is accidental.  Some who do reveal suffer negative consequences, such as being blamed for "seducing" the perpetrator or being accused of lying. One study showed that 52% of those who reported mistreatment to a parent were still being abused a year after the disclosure.

Many perpetrators do threaten the victim that if he or she tells, they might kill someone in the family.  Sometimes they say that the authorities will come in and break up the family - not an unlikely scenario if the child is believed and the parent who is told actually reports the perpetrator.  Other victims are told that no one will believe them.

All good explanations for why the children remain silent.  However, I think that the reason that is talked about the least may be the most important of all:  family loyalty.  Family loyalty as a major determinant of human behavior was focussed on in psychotherapy most notably by family systems pioneer Ivan Boszormenyi-Nagy.  It is also highly consistent with the biological evolutionary concept of kin selection.

Ivan Boszormenyi-Nagy

The strength of family loyalty was illustrated by a patient I saw who had been raised by a female relative rather than by her mother because the mother was a deadbeat parent.  In an initial interview, the patient impulsively blurted out, for the very first time in her life, that the husband of this female relative had continuously molested her.  She immediately burst into tears and could not stop crying for many minutes.

One might assume that memories of the abuse had come flooding back to her and that this was the reason for the emotional breakdown, but as it turned out, that was not it at all.  The woman kept repeating, "I can't believe I told someone!  I can't believe I told someone!"  

After I calmed her down by swearing by all that was dear to me that the session was confidential and no one outside the room would ever have to know what she had revealed, she admitted that her biggest fear was that the woman who raised her would be irreparably hurt by the revelation that her husband had done what he had done.  The patient could not bare the thought that this was what might happen.  She owed the woman just too much.

As Boszormenyi-Nagy stated in his 1986 book, Between Give and Take: A Clinical Guide to Contextual Therapy, "Even very small children are sensitive barometers; they know when their parents are overburdened with anxiety, guilt and mistrust.  Moreover, they want to do something about it." (p.35).  If important relatives are dependent in some way on the perpetrator, children are naturally reluctant to create problems for those relationships.

Many victims of incest dissociate, or zone out, when memories of the abuse surface.  Most therapists assume that this takes place because the incest survivor is trying to avoid the pain associated with the memory.  Undoubtedly this has something to do with it.  However, I find that a much more important consideration with my patients is that they are following a family rule, and do not want to break it out of family loyalty.

When the abuse happened, they were told by the perpetrator in so many words, "This never happened."  When the survivor starts to think about the fact that the incest did indeed happen, they dissociate so that the memories begin to either take on an unreal quality or seem to disappear altogether.   Dissociating may be a way of preventing the sort of accidental revelation to others that took place as described with my patient above.

Monday, April 4, 2011

Book Review

A review of my book, How Dysfunctional Families Spur Mental Disorders: A Balanced Approach to Resolve Problems and Reconcile Relationships, can be seen in this month's (April 2011) newsletter of the National Alliance of Professional  Psychology Providers - a psychotherapy advocacy group.

You can see it on page 11of the newsletter at

An Interview

An audio interview with me about my psychotherapy treatment, Unified Therapy, can be found at:

It is called:

David M. Allen: Unified Psychotherapy: Placing Persons in Their Ecosystem

Saturday, April 2, 2011

Big PhARMA or Big Brother?

An American federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPPA) was supposed to address the concerns of medical and psychiatric patients that sensitive private information about their health might be released to strangers or the public, without their knowledge or consent, by various providers and insurance companies.  While the law increases paperwork for doctors and therefore increases costs, when it comes to privacy protection, it has holes in it big enough to drive a multi-national corporation through.

Accoding to the Privacy Rights Clearing House, "Your consent is not necessary when your information is used by a business associate of your health care provider or plan. Services provided by a business associate can include: legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, and financial. These business relationships are established with a written contract. Your personal medical information can be used to carry on the business association, but you are not a party to the arrangement."

We all know how trustworthy medical insurance companies are.  Government is really more interested in protecting big business interests than your privacy.

A possible new threat to your privacy has recently come to light.  Pharmacies have long been able to compile data on the prescribing habits of various physicians and then turn around and sell the data to drug companies, who want to know who is prescribing their medications, how their salesmen are doing, and also how to shape their sales pitches to the proclivities of the individual physicians.  This process is referred to as data mining.

Of course, they are not supposed to include any information about specific patients, but according to a new article in BNet, The CBS interactive business network, "A new lawsuit alleges that CVS Pharmacies sold its lists to Eli Lilly, Merck, AstraZeneca and Bayer 'by name, date of birth and medications taken.' If true, that’s sobering in terms of patient privacy — do you really want Lilly knowing that you take Prozac?"

They added, "CVS has a lousy history when it comes to [protecting] patient data. In 2009 it paid the FTC a $2.25 million fine for improperly disposing of patient data in a dumpster."

Individual physicians, through an American Medical Association (AMA) website, can elect to "opt out" of allowing their prescribing data to be sold by the pharmacies.  However, many physicians either do not really care if their data is mined, or have not taken the time to opt out.  Many others may not even know that pharmacies do this sort of thing.  They don't teach you about this in medical school.

Busy docs have other things on their minds - it took me longer than it should have to track down the website and take care of this task. 

Of course, it would work a whole lot better if physicians had to opt in in order for pharmacies to sell their information.  But limiting the number of opt-outs is why this is done the way it is done.

I urge everyone to bug your personal physicians to opt out.  They do not have to be AMA members to avail themselves of the opt-out service.  You can even hand them the web link to the correct site to make it easier for them.

The push to use electronic medical records - which might eventually be available on the internet - while helping physicians to gain easy access to important prior  patient medical records, is going to be another big threat to privacy.  This will especially be true for psychiatrists, who deal with the most personal information of all.