Tuesday, April 24, 2012

Guest Post: The Relationship Between Family Dysfunction and Bullying

"Bully" - the Movie

With all of the attention that has been cast on cyber-bullying in recent years as social media continues to explode, as well as the release of the new movie Bully, the issue of bullying on the whole has once again made its way to the forefront of everyone’s minds. It’s certainly not a new topic, but one that surfaces in waves over time, ebbing and flowing in and out of the spotlight, and a topic that begs the question of what really factors in to turning a kid from being a normal child to a bully? There are several potential answers to this question, but dysfunction within the family is a great precursor, and these five examples show how:

1.      Violence at home equates to violence at school
When children are exposed to violence at a young age, whether the violence is directed toward them or towards another family member, they grow up with the preconceived notion that you are able to obtain what you want through violence. This can lead them to believe that the behavior is acceptable, and results in them performing the same actions on others that they’ve learned at home.

2.     Bullying is an outlet for emotional abuse
In addition to physical abuse in the home, emotional abuse is another stepping stone that guides children to adopting a bullying demeanor. When a parent is constantly condescending to their children and is continually battering them and making them feel worthless, kids learn to project this emotional distress on others. Through bullying their peers they are able to release pent up anger that they’re harboring from a less than functional home life, thus temporarily releasing them from the strains of emotional abuse.

3.     Bullying as a way to gain control over some aspect of their life
Being raised in a home where there is an apparent lack of self-control by family members can cause children to want to exercise control over something outside of their home life. Growing up my brother had a friend that was constantly trying to assert his dominance over the other boys his age. He would regularly throw toys at them and tell them how stupid they were. Eventually we found out that his father had zero self-control at home, and while he was obedient at home he projected these pent-up feelings on his friends that were more submissive. This desire to gain control can manifest itself in the form of bullying peers that are perceived as weaker and thus easily dominated.

4.     Bullying as a way to assert self esteem
Children who are raised in hostile and volatile home environments usually suffer from feelings of low self-worth and self-esteem, and can turn to bullying to feel as though they are powerful. These feelings of power can give a false sense of self confidence, and even arrogance, even though in reality bullying is usually a product of having no actual self-assurance. Most of the kids in schools that are known as bullies are deeply unhappy but refuse to admit that fact out loud and are too scared to turn to anyone for help. Instead they act overly confident to compensate for their negative feelings and self-image.

5.     Subliminal encouragement from parents
Parents can end up being subliminal encouragers to bullying as well, even though they may outwardly condemn the behavior. Any indication that the parent actually approves of the bullying, be it through a slip of a smile or a glimmer of approval on their face, can fuel a child to continue with the behavior because they feel they are making their parents proud in some way. The same boy mentioned earlier was never truly punished by his father for being a bully, and so he had no reason to stop with his behaviors. Instead his father silently asserted the behavior thus justifying the boy’s actions. [DA: see my post of February 11, 2011 about the role of Avenger].

There is no easy way to define why children turn to bullying. The causes behind it are complex and varied, and there are likely several underlying stressors that have led kids to turn to his behavior. All we, as the general public, can do is bring as much attention to this issue as possible and help to discourage kids from continuing to behave negatively towards their peers.

Author Bio
This guest post is by Christine Kane, a graduate of Communication and Journalism. She enjoys writing about a wide-variety of subjects including internet providers in my area for different blogs. She can be reached via email at: Christi.Kane00 @

Tuesday, April 17, 2012

Debating Tricks in Arguments about Psychiatry

“Arguing with some true believers is like playing chess with a pigeon.  No matter how good you are at chess, the pigeon is just going to knock over the pieces, crap on the board, and strut around as if it were victorious.” ~ Anonymous

When arguing points in psychology and psychiatry with folks from all ends of the academic political spectrum, it’s easy to see how people become emotionally attached to certain ideas (for whatever internal reasons) and take the position that, “My mind is made up; don’t confuse with me with facts."

Two of their tricks in arguing are:
  • To use a word that has several different senses or referents, and then subtly shift how they are using the word as the argument progresses without admitting that that is what they are doing.
  • Living their lives as if they really don’t believe a word they are saying. 
In today’s post, I would like to illustrate this by discussing two questions:  “What is depression?” and “Is our behavior pre-determined by our past, or do we have free will?”

First, what is depression?  In his great new book, A New Unified Theory of Psychology, my 

colleague from the Unified Psychotherapy Project, Gregg Henriques, quotes Ingram and Siegle, “The label depression has been used to discuss a mood state, a symptom, a syndrome…a mood disorder, or a disease associated with structural abnormalities.” 

Gregg Henriques

[A syndrome is a group of symptoms and/or behaviors that seem to cluster together in many individuals, creates distress or dysfunction, does not include certain other symptoms or behaviors, and has a definitive epidemiology (the incidence and distribution of a disorder in a population, and the sum of the factors controlling its presence or absence].  

These alternate definitions of depression are highly relevant to the question currently being batted around so fervently by all sides, “Do antidepressants work for depression?”  

The answer to the question depends on which definition is being used in the debates.  Especially online, it’s very difficult to tell.  Obviously, if by “depression” we mean a mood state, then of course antidepressants do not always “work.”  If you are merely unhappy about living in a bad situation, taking an antidepressant will in most cases be a colossal waste of your time and money.

Well, what if it’s a syndrome?  Well, at least according to the DSM, which many people seem to use when it suits their purpose but disparage when it does not, there are, at the very minimum, at least four completely different “syndromes” of depression:  Major Depression (with or without the “melancholic” specifier), dysthymia, adjustment disorder with depression, and depression caused by a medical condition or an outside substance like a drug.  So in a “debate,” which one are we talking about here?

In discussions of studies of the effects of antidepressants, this question is often fudged.  Rather than using the names for the two different syndromes major depression and dysthymia, debaters tend to use the terms "mild to moderate depression" and "severe depression."  The "mild to moderate" depression seen in studies is actually much more likely to be dysthymia, while the severe ones are more likely to be major depression.

Clinically, major depression is more likely to respond to antidepressants, while dysthymia is less likely to.  This is complicated by the fact that the definitions of the syndromes overlap to some degree, but making a clinical decision is what medical education is supposed to be about – or at least theoretically. 

The anti-antidepressant crowd loves to point out that recent "meta-studies" show that in mild to moderate "depression," antidepressants are often no better than placebos.  They also conveniently love to ignore the fact that in the exact same meta-studies, the drugs are shown to be highly effective for severe "depression."  

Actually, the use of the word depression is being used here to describe two very different syndromes, but no one mentions that!  

Even the president of the American Psychiatric Association, John Oldham, was guilty of this confusion of terms in a recent editorial in Psychiatric News.

By the way, if you don’t think defining syndromes based on symptomatic and other variables is a valid way to identify diseases, then ask yourself  how people could tell infectious diseases apart before we knew about the existence of germs.

These debates also revolve around another question - whether the syndromes that do tend to respond to drugs are loosely defined mental disorders, or are actually a “disease associated with structural [brain] abnormalities.”

When this question comes up, the people who think that psychiatric drugs have to either be “all good for all people” or “all bad for all people” with nothing in between (you “splitters” know who you are), tend to presume that we have a scientific understanding of the neurochemical microarchitecture of the brain that we are not even close to actually having.  Since that is the relevant science needed to answer this question, at present we are unable to definitively answer it, so we can only make judgments based on a variety of indirect evidence.

The scientific task is made particularly complicated by the existence of neural plasticity and epigenetics.  

Neural plasticity means that the structure and function of the brain changes significantly in response to persistent environmental demands.  This happens in normals.  For example, the part of the brain that controls finger movement is significantly larger in concert violinists than it is in average controls.  So does this mean that being a concert violinist is a disease?  I don’t think so.

Epigenetic influences, loosely translated, means that most genes in any given cell have a switch that turns them off or on – a switch which is also activated in response to environmental contingencies. So, if the average brain of someone with a given psychiatric syndrome seems to be significantly different than the average brain of someone who does not, does this mean that the syndrome is a normal variant caused by a conditioned response, or evidence of a diseased brain?  With our current knowledge of neurochemical brain microarchitecture being so minimal, we cannot answer that question for certain. 

If there are a very large number of brain differences that are unique to a disorder, and some of the differences do not seem to be directly related to the syndrome in question (such as significant differences in eye movements in schizophrenia), then I lean heavily towards the “disease” model for that syndrome. If not, then I lean towards the “normal variant” model.  But I am at least willing to admit that we can’t possibly know for sure given our current knowledge base.  Major Depression is somewhere near schizophrenia in this regard, whereas dysthymia is not.

The epigenetic issue leads us to my second question: is our behavior predetermined or do we have free will?  Of course, people who take the determinist position do not agree among themselves as to exactly what factors are making the determination.  “Determinism” when used by an psychoanalyst means determined by prior psychological events; when used by a radical behaviorist it means determined by prior external events like rewards and punishments. For family systems folk, it means determined by collective forces, and for biological psychiatrists, it means determined by genes.

That so-called doctors and scientists could each completely discount three out of four variables which clearly and undoubtedly affect human behavior is bizarre in and by itself. 

But do any of these determinism types actually live their lives in a way consistent with their professed belief that when we think we are freely and willfully making a choice as to how we are going to behave in a given environment, it is nothing but an illusion?    If so, then their belief in this proposition itself would have been predetermined by one or more of the four factors, and not by the actual scientific merits of their position!  They do not seem to be saying that, do they?

In fact, they live their lives weighing information and anticipating the future in order to make behavioral choices in order to meet their goals.  When they stop doing that, then we’ll talk.

Of course, this admittedly still leaves open the question of the existence of free will.  What do I think?

Well, I believe in free will, although there is no way to actually prove it one way or another.  The idea that may answer the question is actually provided by the radical Skinnerian behaviorists.  They start from the proposition that when a rat is learning to run a maze, if it is rewarded (operantly given positive reinforcement), then the probability that it will behave in the way that was reinforced increases.  (Of course, if food is used as a reinforcer the rat has to be hungry or else this does not work, but that’s a different issue).

In no case does the provision of positive reinforcement lead to a 100% chance that the rat will do anything.

In fact, when we look at all four factors described above, each one increases the odds that certain behavior will ensue.  We could express this probability mathematically as P = p + e + c + g, where P = the probability of a certain human behavior taking place at a given point in time, p = prior psychological experiences, e = external reinforcement by environmental factors, c = collective or social forces impinging on the person, and g = their genome.

I submit that when we add together all four of these factors, P will still not ever reach 100% - there is no certainty or absolute predictability.  If this is true, there would have to be a fifth factor.  Lets call this unknown factor f.w.

Tuesday, April 10, 2012

Are Psychiatrists Who Criticize New Proposals for the Diagnostic Manual Dangerous?

Allen Frances, MD

Psychiatrist Allen Francis was chairman of the task force that developed the last edition of diagnostic Bible in Psychiatry, the DSM.  It was the fourth edition and came out in 1994.  As someone intimately involved in the process of formulating changes in the diagnostic nomenclature, he became concerned when he began to notice that the changes he helped create in the DSM were beginning to lead to the "upcoding" or expanding of psychiatric diagnoses to include normal but problematic variants of human behavior.  

With widespread changes in insurance plans that paid far more to psychiatrists for medicating many so-called "biological" disorders than for providing psychotherapy for what used to be called "neuroses" or "acting out," along with major pushes by pharmaceutical companies to expand the indications of their lucrative new drugs to larger and larger numbers of people, more and more people were being medicated with potentially toxic drugs for what are, for all intents and purposes, disorders of behavior and relationships.  This has been a major theme of this blog.

[For clarification, I should note that diagnoses in psychiatry are not based on the causes of disorders (etiology), but on descriptions of the typical behavior, emotional and cognitive attributes that are seen in various syndromes. A syndrome is a group of symptoms that collectively indicate or characterize a disease, psychological disorder, or other abnormal condition. These characteristics tend to cluster together and can be distinguished from one another using epidemiology (the study of the risk factors, distribution, and control of disease in populations) and the presence of similar descriptions throughout history, as well as through the combined presence of a group of particular symptoms with the absence of other co-occurring symptoms and attributes.

The classification of psychiatric disorders is not based on causes because, in many if not most cases, we have not been able to track down an exact cause (due to our limited understanding of the brain and its relationship to behavior and mentation), and also because almost all psychiatric disorders have multiple biological, psychological, and socio-cultural risk factors.  In fact, "risk factors" rather than "causes" is probably the preferred term that should be used in psychiatry, because there are no necessary or sufficient antecedents to the development of the various disorders.

Nonetheless, all psychiatric diagnoses are not created equally.  Some - like schizophrenia - have been well described, and consistently so, for hundreds of years in multiple cultures.  The defining characteristics of many other conditions, like ADHD for example, are sort of voted on by committees of "experts," many of who have conflicts of interest because they get money from the pharmaceutical companies.  In those cases, the decisions about diagnoses are sort of like the ones made by the Council of Nicaea, during which various Christian Bishops literally voted on which of the many Gospels were the word of God, and which were not].

Dr. Francis has become a leading critic of the plan to come out with a newer edition of the diagnostic manual, to be called the DSM-5 (I guess roman numerals have become passe).  He worries that upcoding will get even worse with many of the new proposals, and medications even more widely mis-prescribed.  And not just by psychiatrists.  80% of anti-depressants, for example, are prescribed by primary care  physicians, and most stimulants by pediatricians.  

And just wait and see what happens if psychologists ever get prescribing privileges, which they desperately seek!  Psychotherapy as we know it may disappear completely.

I also think that, since for most psychiatric conditions we do not know a whole lot more about the causes of the various psychiatric conditions than we did when the DSM-IV was published, coming out with a new diagnostic manual is premature to say the least. Also, since the current research base uses current definitions, changing all of the definitions can be very destructive to building on our scientific knowledge in the future.  

Some of the suggested changes seem to center around the idea of "spectrum" disorders, in which various disorders are grouped together because some of the symptoms sort of look alike.

Just recently, the American Psychiatric Association (APA) recruited a new public relations spokesman, formerly of the US Defense Department, who was quoted as saying that "Francis is a 'dangerous' man trying to undermine an earnest academic endeavor."  It sounds like, rather than address the well-thought-out criticisms of Dr. Francis, the APA has elected to circle the wagons defensively and engage in ad hominem attacks. 

In response, Dr. Francis posted a rebuttal in a psychiatric newspaper.  Allow me to quote his very cogent response:  

"The piece in Time Magazine manages to raise again the silly APA suggestion that my objections to DSM-5 are motivated by a feared loss of royalties. Let’s set the record straight—hopefully for the last time. The royalties on my DSM IV handbook are about $10,000 a year—not at all commensurate with all the time I have spent trying to protect DSM-5 from making all its repeated mistakes.

"My motivation for taking on this unpleasant task is simple—to prevent DSM-5 from promoting a general diagnostic inflation that will result in the mislabeling of millions of people as mentally disordered. Tagging  someone with an inaccurate mental disorder diagnosis often results in unnecessary treatment with medications that can have very harmful side effects. I entered the DSM-5 controversy only because I had learned painful lessons working on the previous three DSM’s, seeing how they can be misused with serious unintended consequences. It felt irresponsible to stay on the sidelines and not point out the obvious and substantial risks posed by the DSM-5 proposals.

"I don’t consider myself a dangerous man except insofar as I am raising questions that seem dangerous to DSM-5 because there are no convincing answers. My often repeated challenge to APA—provide us with some straightforward answers to these twelve simple questions:

1.   Why insist on allowing the diagnosis of Major Depressive Disorder after only two weeks of symptoms that are completely compatible with normal grief?
2.   Why open the floodgates to even more over-diagnosis and over-medication of Attention Deficit Disorder when its rates have already tripled in just 15 years?
3.   Why include a psychosis risk diagnosis which has been rejected as premature by most leading researchers in the field because it risks exacerbating what is already the shameful off-label overuse of antipsychotic drugs in children?
4.   Why introduce Disruptive Mood Dysregulation Disorder when it has been studied by only one research team for only six years and risks encouraging the inappropriate antipsychotic drug prescription for kids with temper tantrums?
5.   Why sneak in Hebephilia under the banner of Pedophilia when this will create a nightmare in forensic psychiatry?
6.   Why lower the threshold for Generalized Anxiety Disorder and introduce Mixed Anxiety Depression when both of these changes will confound mental disorder with the anxieties and sadnesses of everyday life?
7.   Why have a diagnosis for Minor Neurocognitive Disorder that will unnecessarily frighten many people who have no more than the memory problems of old age?
8.   Why label as a mental disorder the experience of indulging in one binge eating episode a week for three months?
9.   Why introduce a system of personality diagnosis so complicated it will never be used and will give dimensional diagnosis an undeserved bad name?
10. Why not delay publication of DSM-5 to allow enough time to complete the previously planned and crucial second stage of field testing that was abruptly cancelled because of the constant administrative delays in completing the first stage?
11. Why should we accept ambiguously worded DSM-5 diagnoses whose reliability barely exceeds chance?
12. And most fundamental: Why not allow for an independent scientific review of all the controversial DSM-5 changes identified above—proposed by 47 mental health organizations as the only way to guarantee a credible DSM-5? What is there to hide and what harm is done by additional careful review?

"If I am a dangerous man, it is because I am exposing DSM-5’s carelessness and thus putting at risk APA’s substantial publishing profits. During the past 3 years, I have made numerous attempts, private and public, to warn the APA leadership of the troubles that lie ahead and to implore them to regain control of what was clearly a runaway DSM-5 process.

"This has had no real effect other than delaying publication of DSM-5 for a year and the appointment of an oversight committee that turned out to be toothless. I am reduced now to just one means of protecting patients, families, and the larger society from the recklessness of the DSM-5 proposals—repeatedly pointing out their risks in as many forums as possible."

Well said, my good man.  It seem to me that the APA is at risk of being dangerous, not Dr. Francis.

Tuesday, April 3, 2012

Well-Meaning Blacks and Whites Continue to Talk Past Each Other About Race

In dysfunctional families, one common attribute that most people have makes it difficult for them to resolve their differences in a constructive way in order to solve family problems. Each family member becomes so convinced, and can give a lot of evidence for, their own ideas about what is going on that they do not seem to listen at all to the other person’s point of view.  

When the other person gives his or her point of view, family members tend to invalidate the other by merely restating their own point of view, as if the other person had not said anything at all.  And rare is the dyad in a family that considers the idea that they may both be right and that their views are not really incompatible at all.

Another one of the major points in my ideas about dysfunctional families is that the problems commonly seen in these families often represent a sort of microcosm of the very same conflicts seen in larger groups within their particular society.

I saw an interesting example of this that stems from the discussions of racism that were triggered by the recent murder of Treyvon Martin.

There was an interesting posting of two “dueling” op-ed pieces in the Memphis newspaper on March 28, 2012: one by a Black columnist, Walter E. Williams, and one by a White columnist, Frank Cerabino.  Strangely, the Black columnist took the position that I have seen usually taken by Whites, and vice versa.

Frank Cerabino
The main point of Cerabino’s column was that if the roles were reversed – if a White man was killed by a Black person who was serving on a Neighborhood Watch, then the shooter would have been arrested immediately.  The columnist even had a real life example to give that illustrated his point.  Cerabino also thought that if the shooter Zimmerman had been Black and Martin White, that the shooter would have been held without bail. The obvious implication is that society is still far more racist than it often claims to be.

Walter E. Williams
Williams, taking the traditionally White argument, points out why in our society “Black and young” has become synonymous with “crime and suspicion.”  Furthermore, he believes that this equating these two is not always based on racism, but more often on our universal tendency to profile strangers on the bases of categories that represent higher versus lower risks to ourselves.  Even African-American cab drivers and pizza delivery men avoid certain Black neighborhoods, he points out, because of concerns about their safety. 

Most people are familiar with the statistics about young Black males that show that they represent a disproportionate share of all the people who commit violent crimes, and therefore such determinations are not actually racist but more statistical or something like that.  And parenthetically, most of their victims are other Black people, not Whites. “We humans are not Gods,” Williams says, “therefore, we must often base our decisions on guesses and hunches…based on easily observed physical characteristics…”

The justaposition of these two articles reminded me of a segment of the now defunct news magazine show Primetime Live that was broadcast twenty years ago.  It seems like the arguments have changed very little over that period of time.

PrimeTime Live
The segment was entitled “True Colors” and was broadcast on ABC on September 26, 1991.  Documentary filmmakers had two men of the same age, one Black and one White, go out to society and apply for jobs, try to rent an apartment, and browse the aisles of different stores.  The two men had been trained to present themselves in an identical manner.  Both were equipped with similar histories (education, employment histories, credit scores, and so forth), and both appeared to be upper middle class.  They were dressed as one might expect the White man to be dressed, and both spoke English in the standard White dialect.

In some instances, they were reportedly treated the same by society, but many times this was not the case.  Jobs that were “open” to the White applicant suddenly became “filled” when the Black applicant showed up just a short time later.  The Black guy was followed around by the help in a variety of stores as if he might shoplift something at any moment – but this did not happen to the White guy when he came to the same store.  Potential landlords would lecture the Black man about such things as paying the rent on time, and did not appear particularly welcoming to him.  Again, the White man got a royal welcome and no lectures.

After the film was shown, members of a discussion group organized by the TV show began to express very similar points to those expressed by the two columnists in the Memphis newspaper.  

Tellingly, neither side (and the Whites and Blacks in this case took the expected sides) was willing to concede that the other side’s point had any validity at all.  Instead of a engaging in problem-solving about what to do about this dreadful state of affairs, the discussion just degenerated into an argument.

Now, in all of these cases, I believe that the discussants and writers involved were not overt racists, white supremacists, or black supremacists – remember the newspaper writers actually took the opposite positions from their television counterparts.  Even Jessie Jackson once said that if a young black male stranger were walking behind him in some circumstances, he would feel somewhat threatened.

So which side is right in this debate? 

Duh!!  Both are.  

Subliminal and not-so-subliminal racism is far more prevalent in White society than one side cares to admit.  And young Black males are on average more likely to be a significantly higher risk to a stranger than a young White counterpart.  On Primetime, the side arguing for the former proposition (and arguing as if the other side's argument could not possibly also be true) argued that the Black man in the film was nicely dressed, not speaking in Black slang, and very polite – and yet he was still treated as if he might be a member of the Crips or something.  

Quite true!

In fact, considering American history, it might seem that Blacks should be more threatened by Whites than the other way around.  In my lifetime, TV production codes prohibited the depiction of financially successful and well adjusted Black people.  

And then there was the terrifying documentary on PBS recently about the “felon leasing program” that took place in the South after Reconstruction and continued well into the twentieth century.  Black men were routinely arrested on trivial or flimsy charges, convicted by all-white jurors, and then leased out as slave labor for various businesses.  Victims were treated even worse than slaves because, in this situation, they did not represent valuable “property.”

Even today, being African American can lead you to get a longer sentence than for a White when being convicted of the same crime.  Until very recently, sentences for crack cocaine (used more often by Blacks) were far longer than sentences for powdered cocaine (used more often by Whites).

On the other hand, as I argued in my blog post The N-Word, a significant proportion of Blacks often do, in fact, act in accordance with old White stereotypes of Black people.  The reason is that doing so had survival value in more racist times – times that were not at all that long ago. For example, the Black comedian Chris Rock jokes about a Black motorist in the Old South who was shot to death at a stop sign by a White policeman - because he could read the sign.  Unfortunately, when Blacks of today act as if they do not want to be educated, it reinforces the Black stereotype for Whites.

In order to solve the problems of racism for both Blacks and Whites, we all need to start trying to be empathic to all of these points of view, and validate each other whenever we can.  We need to stop being so defensive and actually listen to each other.  Stop arguing and start putting our heads together!