Thursday, July 28, 2011

Are We as Individualistic as We Like to Think?

When we see Iranian Shiite Moslems parading down the street during the day of Ashura, cutting their own foreheads and literally whipping themselves into a frenzy during a religious ceremony, we often come to the conclusion that the entire country has gone stark raving mad.

Surprisingly, however, we all do the same thing to a much lessor extent. As I described in previous posts Of Hormones and Ethnic Conflict and The Meaning of Life, we systematically discount our own natural tendencies to subjugate ourselves for the good of the group to which we belong. In particular, if our family system requires us to squeeze our thoughts and behaviors into some pigeonhole, we too will find ways to force behaviors upon our­selves which are otherwise unnatural for us. We sense that our impulses to do otherwise must be destroyed.

The ways in which we accomplish this are all subsumed by the term mortification. In recent times the word mortification has come to mean something akin to severe embarrassment or humiliation, but that is not what the word meant originally.

In the Oxford English Dictionary (first published in 1933 and reprinted in 1961), we find among the different senses of the word the following definitions: 
  • Mortification. In religious use, the action of mortifying the flesh or its lust; the subjugation of one's appetites and passions by the practice of austere living, especially by the self infliction of bodily pain or discomfort. (p. 678).  
  • Mortify. To bring into subjection (the body, its appetites and passions) by the practice of self denial, abstinence, or bodily discipline. (p. 679).  
  • Mortifying. Involving mortification or repression of natural appetites and desires. (p. 679)  
In earlier times, mortification was viewed as a conscious process by which one constrained one's own behavior within certain narrowly defined limits. Individuals actively searched for ways to push away those natural inclinations that were not in keeping with group norms. They figuratively tried to kill them off.

In particular, people felt that they had to keep a rein on their "animal" impulses. These impulses came to be known as the seven deadly sins: pride, greed, lust, anger, gluttony, envy, and sloth. These" sins" might be seen as roughly corresponding to Freud's concept of the id.

Not surprisingly, skill at mortifying oneself was most thoroughly developed in austere religious orders. By becoming involved in large numbers of compulsively-performed rituals (some of which bordered on the bizarre), members of such orders had little time for self-indulgence.

Even so, the process of mortification through discipline, abstinence, and compulsive behavior was deemed to be ineffectual. No one short of Jesus' could be that perfect. For this reason, most of these groups also had some form of confession - a ritualized self-denunciation in front of the group or its leader - to cleanse from the soul the remnants of self-seeking tendencies.

Most people nowadays are not aware of the importance of the process of mortification in everyday life. This lack of awareness is most likely due to prevailing individualistic values. The loss of such understanding is, however, of relatively recent vintage.

The Victorians in England were certainly aware of mortification, although by around the turn of the century before last it was already the focus of some derision. It was satirized by name in no less than three Gilbert and Sullivan operettas.

In The Mikado, a character named Pooh Bah has to "mortify," not only his own pride, but his family pride. He does so, however, in order to save his own skin. It seems that in order to save his town from losing its charter (something which represents a collective need), someone has to volunteer' to satisfy the whims of the Mikado (the king) by allowing himself to be executed. Pooh Bah declines to volunteer, justifying his refusal on the grounds that it is necessary for him to refuse to indulge his family pride.  Family pride, he argues, would be served rather than mortified by his accepting the job.

In Iolanthe, the queen of a group of fairies has to "mortify" her sexual attraction to a mortal man, and has a problem doing so after one of her favorite subjects has been caught marrying a mortal. This play satirized societal prohibitions against marry­ing across the rigid class lines present in the England of that day.

In Princess Ida, women in a feminist school have to "mortify" their attraction to men in order to maintain their group identity. The mortification, as well as the group identity, dissolves when the school is infiltrated by some charming and handsome young men.

From my point of view, the impulses that are most often mortified by today's individuals can be conceptualized as being those inclinations of their real selves which conflict with the roles that they have been playing within their families. People have acquired these roles because the roles seem to be required in order to maintain family homeostasis.

In Chapter 3 of my book A Family Systems Approach to Individual Psychotherapy, I discussed several ways in which individuals try to rid themselves of some of their own impulses. Some of the forms of mortification that I described correspond to the psycho­analytic concept of defense mechanisms. In general, modern families and individuals have to do for themselves what was once done for them by the larger group.

Where we once had group censure and political exile, we now have family invalidation and emotional cut-offs. In place of fire and brimstone from a preacher, individuals create their own frightening, irrational thoughts in order to scare themselves out of this or that desire. Instead of going to the confessional, they criticize themselves for their base inclinations and find ways to loathe themselves. Rather than engaging in prescribed rituals, they form their own reaction formations, compulsively acting in ways that run counter to their underlying desires. We have all devised ingenious ways to put ourselves down, subjugate our passions, and force ourselves to conform to collective standards or family needs.

Saturday, July 23, 2011

Practice of Doping up Children to Treat Parental Anxiety Continues to Grow

I have already written several posts about the inappropriate "diagnosing" of bipolar disorder in children and the even more inappropriate use of antipsychotic medications in children.  My main point has been that, rather than having a psychiatric disorder, the vast majority of these children are just acting out.  (For those readers who have difficulty making distinctions - especially those who automatically assume that things that look vaguely alike must be identical - this opinion does NOT apply to those uncommon children who are actually psychotic or to older adolescents who are clearly and obviously manic).

So what proof can I offer?  Well, at the American Psychiatric Association Annual Meeting, John Goethe, MD (director of the Burlingame Center for Psychiatric Research and Education at Hartford Hospital’s Institute of Living), presented the results of a decade-long study of antipsychotic prescribing for children and adolescents in psychiatric hospitals.

The results? Forty-five percent of patients with such behavioral disorders as ADHD or conduct disorder were given antipsychotics and 44% of patients with post-traumatic stress disorder (PTSD) received them. The percentage for other anxiety disorders was 31%!

Forgetting for the moment that an ADHD diagnosis may just be yet another case of acting out, antipsychotic medication is not indicated for ADHD.  In adults, antipsychotic medications are not indicated nor FDA-approved for any anxiety disorder or PTSD.  Not only that, but there is not the slightest evidence from any neurobiological study that the purported mechanism of action of antipsychotic medication has anything to do with anxiety disorders or ADHD. 

And conduct disorder?  This "disorder" was formerly called juvenille delinquincy.  Acting out by any other name. Don't even get me started.

One of the predominant side effects of these medications, is however, sedation.  So one might conclude that the reason the meds seem to both the parents and incompetent doctors to "work" is that the kids quiet down because they are being doped up. (This prescribing practice does not just apply to some psychiatrists but also to many other primary care doctors as well -as to pediatricians, read Claudia Gold's blogpost, Pediatricians Prescribing Psychiatric Medication: A Dose of Reality),

But who's anxiety is really being treated here? 

I submit that it is the anxiety of the parents. Parents who have out-of-control, acting-out children are the real objects of these "treatments."  These parents covertly feel guilty when they are unable to control their children due to inconsistent, neglectful, or abusive parenting practices.  Yet they have great difficulty changing these practices for a variety of reasons - sometimes very understandable reasons.  (One of which is that their doctors make no effort to understand what is really going on in their homes, and take advantage of their insecurities). 

Nonetheless, when the kids are doped up and are therefore less trouble, the parents feel better. And they have the doctors stamp of approval that the problem resides entirely within the child, not with them.

An unsolicited plug

The use of these drugs in kids diagnosed with PTSD is particularly instructive.  Unless you are treating victims of such disasters as the recent outbreak of tornadoes in the South and Midwest, or working with victims of crime like Jaycee Dugard, the most common trauma leading to PTSD in children is child abuse.

Of course, this whole process of sedating acting-out children usually does not end with the first prescription.  For most drugs that have sedation as a side effect, the sedation gradually subsides after  a few weeks on the medication.  Then, of course, the kid starts doing what kids always do - start reverting back to their previous behavior.

The parents then drag him or her back to the incompetent doctor, who starts to take one of the following steps and then another, in no particular order:
  1. Increase the dose of the medication.
  2. Change to a different medication which also is not indicated for anxiety and conduct disorders.
  3. Add a prescription for a second one of those medications, and then perhaps a third or a fourth.
  4. Change the diagnosis to something else other than acting out, and begin the whole process all over again.
Since the kid still is not controlled after the sedative side effect subsides, another step the parents can take is to apply for social security disability for the child.  This gives the child the message that the parents think he or she is both sick and incompetent.

Readers of the blog know what I believe happens next.  The child develops a false self that only seems to be sick and incompetent.  Such children hide their abilities as they grow into adults, continue to act in ways that preclude employment, and continue on social security disability. 

When you take the time to actually get to know them, however, it seems that the only thing they can not seem to do that most people can is maintain employment.

And then Robert Whitaker thinks that the medications were the cause of the disability, just like the less-than-thorough doctors thought that the medications caused the initial improvement of the child's "mental illness" when it was just a side effect that temporarily muted acting out behavior. 

It always amazes me how much people who seem to be on opposite sides of a debate think alike.  Basing their conclusions on totally incomplete information seems to be a favorite blind spot of theirs.

Monday, July 18, 2011

The Meaning of Life

Existential philosophers express a great deal of angst about four different concerns:

  • The knowledge we have that we will all die eventually
  • The freedom to be the author of your own life (as opposed to doing what your society wants you to do)
  • Isolation (the feeling that there is an unbridgeable gulf between ourselves and others, as expressed in the sentiment "you come into this world alone and you die alone"), and
  • The meaning of life.
Irvin Yalom, an influential psychotherapist, believes that these are the four areas of concern most important in the genesis of psychological problems, rather than, as the Freudians believe, biological urges like sex and aggression. 

Irwin Yalom
He thinks that the traditional psychological defense mechanisms are aimed at the avoidance of the anxiety that is created when one ponders these "existential" concerns, rather than anxiety over forbidden impulses. In particular, religion is seen as a form of self-delusion designed to protect one from a sense of meaninglessness in an absurd universe in which everyone eventually dies with no guarantee of an afterlife.

Everyday people, on the other hand, tend to think that worrying about such abstract concerns is the province of crazy intellectuals and bored housewives with too much damn time on their hands.

Not so! Granted, those people who are completely engrossed in just trying to survive do not have much time to think about such things, but most individuals in industrialized country are not completely consumed with finding food and shelter.  And most people seem to feel that their life has meaning, even if they can not precisely define it, so they do not seem to worry about looking for it. 

What they may not realize is that they may only feel that way as long as they do what they believe they are "supposed" to be doing.  There is something comforting about following rules and not having to think too much about what existence is all about. 

Erich Fromm wrote a book called Escape From Freedom that put forth the proposition that people are rather fearful concerning the prospect of complete freedom.  If they can do whatever they please, perhaps they might make an terrible error.

The rules about what one was supposed to do in life used to be much clearer than they are now for the majority of people. Various institutions like schools and churches laid out your options for you, and you went along. Even when you technically "broke" the rules, you were often validated by your friends for having done so.  In a sense, the answer to the question of which rules could be broken in private (though not in public) was actually covertly specified by the rules themselves!

Things have changed. Culture has evolved to our current "post-modern" society where all bets are off, and different value systems compete with one another. One often hears that many different points
Erich Fromm
of view are of equal validity.  Your family itself may be divided over the validity of certain values and societal mandates.

So, every so often, almost everyone is overcome by a sense of doubt about who they are and the choices they have made, as well as an existential sense of the meaninglessness of all of it.  However, because most of us will go to any length to avoid feeling that way - let's call this feeling groundlessness - it usually does not very last long.  And so we think that this feeling cannot be very important.

In therapy, on the other hand, when we try to help patients follow their own muse, so to speak (self actualize), they often find themselves at odds with a set of rules that they had learned in their families of origin.  And when they begin to experiment with breaking those rules, a terrifying sense of groundlessness begins to manifest itself.  The feeling is so distressing that patients may think they are getting worse, and may even start to seriously contemplate suicide. 

The descriptions they give of the feeling in psychotherapy are fascinating.  Yalom discusses something he calls de­familiarization. In the normal course of everyday life, we feel at home in the world; we feel connected. Everything in the world about us - objects, people, roles, values, ideals, symbols, institutions, and even the sense of who we are in relationship to the rest of the world - seems comfortable, fa­miliar, and meaningful.

This meaning is reassuring and provides a sense of belonging, for while it is to some extent personal, it is more primarily collective. We share much of our sense of mean­ing with others within the particular systems in which we operate.

Defamiliarization is a disturbing feeling that all is not well, that the outward appearance of the world disguises the fact that its meaning and purpose are not at all clear. This strange feeling is part of the sense of groundlessness.

To again quote Yalom, we gain a terrifying sense that "everything could be otherwise than it is; that everything we consider fixed, precious, good can suddenly vanish; that there is no solid ground; that we are 'not at home' here or there or anywhere in the world." Life begins to seem absurd and pointless, utterly devoid of significant meaning. Pushing on with one's goals begins to seem like an exercise in futility; what's the point?

All that one holds to be important takes on a cast of silliness and, ultimately, unreality. The sense of unreality brings with it something that is even more unnerving, if that be possible, than the sense of meaninglessness: the aforementioned paralysing doubt. If everything one holds to be gospel is not at all real, then perhaps what I think I know I do not know. And maybe it is just me. Maybe I am wrong, but everyone else is right. Maybe what I feel is invalid; maybe I am a nothing.

One patient described the feeling thus: "I felt my identity disintegrate. My career was in jeopardy. Little flags of doubt about what I was doing led to a depression. I felt like a zero." Another patient described a feeling that she was "neither fish nor fowl." Yet other statements made by patients that indicate groundlessness include the following: "I felt as if I were on a different plane from everyone." "I felt I was overstepping my bounds." "I felt disconnected." "There was a barrier between me and everyone else." Patients may complain of feeling "amorphous" or "undefined and void."

How much more comfortable to go back to following all of the old familiar rules, even if they make you miserable in every other conceivable way. The pull of the family system to go back to the family rules is a very powerful one, both in one's relationships and in one's own mind.

This feeling may be our brain's way of expressing a biological tendency that we have inherited to sacrifice ourselves for the sake of our family or ethnic group, or to die for one's country.  This innate tendency, called kin selection, was discussed previously in my post of January 21, Of Hormones and Ethnic Conflict.

Being part of a group and belonging to something that will continue on after we pass away also gives us a modified feeling of immortality that makes death somewhat less frightening.  It eases the sense of ultimate aloneness, and it give our lives meaning.  Plus, we do not have to make the types of decisions that make freedom frightening. In short, it provides answers for us, flawed as they may be, for all four existential concerns.  No wonder psychotherapy with the goal of helping someone self actualize is so difficult.

Wednesday, July 13, 2011

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.

Friday, July 8, 2011

Ve Have Vays of Making You Talk - Part III: Blame Shifting

In Part I of this post, I discussed why family members hate to discuss their chronic repetitive ongoing interpersonal difficulties with each other (metacommunication), and what usually happens when they try.

I discussed the most common avoidance strategy - merely changing the subject (#1) - as well as suggested effective countermoves to keep a constructive conversation on track.  In Part II, I discussed strategies #2 and #3, nitpicking and accusations of overgeneralizing respectively.  In this post, I discuss strategy #4.

To review, the goal of metacommunication is effective and empathic problem solving. In this post, I will discuss another avoidance strategy that I call blame shifting, as well as appropriate counter-strategies. 

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

Strategy #4: Blame Shifting

A favorite maneuver that is used by many families members to scuttle metacommunication is the counter-accusation. The counter-accusation may be aimed at the metacommunicator, or it may be aimed at a third party. 

For metacommuncation to succeed, people best take the  position that there are NO villains in the family drama. However, family members, including the metacommunicator, may have done very bad things, and that fact cannot be ignored without the ignorer sounding like a liar or an idiot.  

As I have said before, blame is toxic to metacommunication, and leads to fight, flight, or freeze reactions in others, none of which is productive.  No one wants or needs to eat crow, as it does not taste like chicken.  The important thing is to begin the process of changing problematic patterns in future interactions.

Individuals attempting to discuss a mutual problem with a family member without placing blame on anyone must usually bring up the Other's troublesome behavior within the family system. Even when individuals do their best not to blame anyone, the Other may nonetheless attempt to quiet them by acting as if they were behaving in a blaming manner.

Let's take the case in which the Other (O) becomes indignant and starts placing the blame for the problem on the Metacommunicator (M). In order to get M to become especially angry, O may magnify and exaggerate M's contribution to the problem and imply that M is entirely at fault.

This kind of maneuver is, of course, an attempt to distance M through the use of an unjust criticism. M will be sorely tempted to return the insult in kind. As with any other distancing maneuver, however, M should instead react by moving closer.

The biggest difficulty in designing an effective countermeasure for this maneuver is that the accusations of O will invariably contain a kernel of truth. M, being an integral part of the family system, is indeed part of the problem. If M reacts to O's accusation by merely defending himself, O will have and may use a wealth of examples from M's past as ammunition to back up his or her charge. M may then begin to become frustrated, angry, or feel guilty about his or her contributions to the family problem, and the conversation will sidetrack.

Luckily, however, the fact that the O's accusation does contain a kernel of truth can be used to get the conversation back on track. It can be used in the service of empathy.

Instead of becoming defensive, M can acknowledge the kernel of truth in the O's accusation, while either ignoring the exaggerations or pointing them out in a matter-of-fact fashion. M can then use his contribution to the problem as an example of behavior that is caused by the very family problem that they are now trying to discuss and solve. M can add that he used to criticize himself for the very "sins" of which O is now accusing him.

As we shall see in the following example, M can also use O's criticism to question traditional family beliefs. The latter subject is normally one of the last parts of the metacommunicative sequence that comprises effective metacommuncation, but O's blame-shifting maneuver provides an excellent vehicle for speeding up the process.

Mr. M, estranged from his family and living far away, was in the process of calling up his older brother to metacommunicate about a family problem. Mr. M let the brother know that he wanted to come home on vacation to clarify some of the family issues. The brother, who had attempted but failed to escape enmeshment in the family by moving away as M had done because he had felt obliged to return, immediately began to indignantly criticize M's attempt at renewed family involvement. "You moved away and have your own life. Who the hell are you to come back here and try to fix the family?"

(As an aside, there is hidden altruism in the brother's seemingly hostile response:  he was trying to help Mr. M stay away from what the brother considered to be a toxic family situation.  Responding to the lexical content -just the words - will be the subject of a future post).

M responded, "I can understand your feelings. I often asked myself that same question when I first considered doing this. I have been away a long time, but I'm not happy about not being close to the family." The goal of this statement was to use it as a vehicle for bringing up the difficulty that the entire family had in resolving the riddle of how to remain close to one another while leading independent lives.

In response, however, the brother let go another accusation - one that the patient had often used on himself to discourage himself from trying to return to the family fold. The fatalistic belief that underlay this particular accusation was at the core of the family problem. (More on fatalism in a future post in this series).

"Look," protested the brother, "forget it. You're just going to stir up trouble. The people in the family are not going to change. Dad's been drinking for years, and he isn't going to stop. You're not going to save anyone."

The accusation that he was trying to be the family savior and that this was a major cause of trouble was particularly effective on M.  He had attended a self-help group for years, and the avoidance of the rescuer role was one of the hallmarks of their message. Indeed, the fatalism of the family made that organization and its message seem reasonable to the patient.

M reminded himself that he was not responsible, ultimately, for making the family change, but he could change the way that they related to him.  M empathized with the brother's feelings that the family members were fundamentally and irreparably damaged. He had, after all, felt that way himself many times. He could truthfully say, "I used to think that way, too." After expressing this empathy, he was in a position to question the validity of this assertion and to discuss the historical and cultural reasons that led to the family's fatalistic belief system.

Now let us take the situation in which O shifts the blame off of him- or herself and attributes the problem entirely to the behavior of a third family member.  M may also be annoyed at the third party, so itis very easy for both parties to stop talking about their problems with one another, and non-productively start in on the other guy.

Alternatively, the metacommunicator may feel the urge to defend the other guy. Even when certain family members may be furious at, say, Dad themselves, they will often defend him if anyone else attacks him. That's just the way people are - very protective of their kin group.

In this case, the counter-strategy involves validating O's point of view about the third party without necessarily agreeing with it, and avoiding going off on a non-productive tangent.  M can say something to the effect that, "Everybody in the family seems to get embroiled in this problem to some extent.  I plan to talk to [third party] as well.  But let's talk about how this plays out between the two of us.  I really would like for us to get along better."

Saturday, July 2, 2011

Biederman and Colleagues Finally Get.... a Slap on the Wrist.

From the July 2 Boston Globe (

"Concluding a three-year investigation, Massachusetts General Hospital and Harvard Medical School sanctioned renowned child psychiatrist Dr. Joseph Biederman and two colleagues after finding they violated conflict of interest rules...

Joseph Biederman

...They did not specify the nature of the violations. But in 2008, Senator Charles Grassley, an Iowa Republican, accused the three doctors of accepting millions of dollars in consulting fees from drug makers from 2000 to 2007, and of failing for years to report much of the income to university officials...

...They said the institutions imposed remedial actions, requiring them to refrain from all paid industry-sponsored outside activities for one year, with an additional two-year monitoring period during which they must obtain approval before engaging in paid activities. They were also required to undergo unspecified additional training and suffer 'a delay of consideration for promotion or advancement...’'

...“It’s hard for me to make that judgment, but this all sounds like a little slap on the wrist,’’ said Dr. Jerome Kassirer, a Tufts University School of Medicine professor and outspoken critic of close ties between the drug industry and physicians. He pointed out that Biederman is a full professor at Harvard Medical School, so it’s unclear how a delay in promotion or advancement would affect him. Also, Biederman severed his industry ties soon after Mass. General and Harvard began their separate but coordinated investigations...

...Biederman is the country’s most prominent advocate of diagnosing bipolar disorder in children, even in those under age 6, and using antipsychotic drugs to treat many of them."

Really, in my opionion, these people should be in jail for perpertrating scientific fraud and for launching the trend of inappropriately drugging children who are merely acting out.

America's True Death Panel