Where the Analysts Went Wrong: Part II

In the introduction to this post, I mentioned that a major problem with psychoanalytic formulations concerning the origins of personality dysfunction is that they presume that problematic interactions with parents and other family-of-origin members are only powerful in shaping personality functioning with young children.

When I first started getting interested in family systems ideas and started asking my adult patients about their current interactions with their parents and other members of their families of origin, it soon became clear that some of the interactions followed certain patterns than recurred again and again, and that these patterns served as triggers and reinforcers, as a behaviorist therapist might say, for the very feelings and behaviors that the patients were coming to therapy to try to change. 

Until I started asking about these interactions, as I described in my post Don’t Ask Don’t Tell, the patients had not described them in much detail. When they broke out in tears while telling me about them, however, it became hard for them to deny that the interactions were at least part of what was making them feel bad.

These were patients in individual psychotherapy, so I was not a first hand witness to these interactions, although later I found ways to see them in person. And my psychoanalytic and behaviorist psychotherapy supervisors had not discussed what to do about them.

It seemed to me that if my patients were just more assertive with their families, they might be able to change these problematic family interactions. The behaviorists had taught me about something called assertiveness training, so I tried that. The first time I tried it, I tried to teach a Chicana woman to stand up to her father. She wanted none of that. Wouldn’t even really discuss it. So, I thought, maybe it’s some sort of cultural force that I was up against in this particular case.

So how about with a patient from a somewhat more egalitarian culture? I taught an Anglo woman with traits of borderline personality disorder (BPD) to be assertive with her family. Her parents seemed to be subtly sabotaging her efforts to establish independence from them. When she was doing well, they ignored her. Or more like gave her the silent treatment and a cold shoulder. When she was in financial trouble, however, they were always right there to help out -although strangely they gave money to her teenage son rather than to her!

Every week in therapy she would dutifully practice assertiveness techniques, and would leave the session confident that she could address the issues with her family. The very next week, however, she would come back with her tail between her legs.  Her best efforts seemed to have been totally defeated, and she became even more unhappy than she had been, and even less self-confident.

I discovered that as a therapist I was absolutely no match for this woman’s parents in affecting her behavior, either for good or for ill. And it was not just her. I found out – again and again - that parents were way more potent influences on the patient than I as a therapist could ever be.

Behavior therapists do not seem to have figured out that the interactions of a patient and his or her family of origin are important triggers to many of the complaints that patients come to therapy with. Nonetheless, their behavioral interventions do often change certain aspects of a patient’s behavior, and therefore they feel that their patients are responding to treatment. In fact, if a patient’s family of origin is not too dysfunctional, they are correct. The patients change their behavior and the family basically accepts the change, so everything is cool.

But in significantly dysfunctional families? Not so much. The family therapists were right. The entire family will confront the patient in a variety of ways that all boil down to the message, “You are wrong, change back.” Many times I have even seen relatives such as aunts and uncles who previously had had little involvement with the patient come out of the woodwork screaming, “How can you do this to your mother?!?”  

Sometimes the situation would escalate to incredible extremes, with parents figuratively sticking their heads in the oven threatening suicide in response to the patient’s meager attempt at self actualization, or doing what they want and not what the parents seem to want. 

The psychoanalyst Karen Horney once opined that “basic anxiety” requires a sense of isolation from others, helplessness, and of being surrounded by hostility. Such perceptions and cognitions are closely related to attachment to others in one’s family system. The human brain encodes social events from the family exceptionally well, and is exquisitely sensitive to them.

“But,” I hear you protest, “a lot of patients with personality disorders are highly oppositional to their parents, seemingly doing the exact opposite of what the parents say that they want. So that theory can not be right!"

My answer to that: these people are oppositional to their parents because that’s what they think the parents need from them. The parents seem to need them to be black sheep. For a further discussion of this point, I refer you to my post about the role of the spoiler.

New developments in neuroscience are consistent with the proposition that parents can have strong effects on their children even as adults, even if they do not want to. Studies have shown that the perception of faces activates specific cells in the amygdala, which is the part of the brain responsible for fear reactions. Different cells there respond to different facial features, and certain cells respond only to one parent or the other. 

The amygdala is also strategically located for generating a rapid and specific autonomic nervous system and endocrine pattern in response to complex social signals. Lesions of amygdala in primates cause an inability to appraise social signals from other members of same species. An afflicted individual cannot distinguish whether another member of their species is coming towards them to fight with them or to mate with them. And again this is in adults, not juveniles.

In general, the attachment system seems to be one of the most important regulators of overall arousal. The amygdala is the first responder within fractions of a second; one’s initial fear orientation is not affected by conscious cognition. However, the signals then go to the other areas of the brain for further evaluation. Information regarding social context directly affects this appraisal process.

Attachment research indicates that the brain regions that compose the limbic system use input from the emotional states of attachment figures to regulate both internal and external responses. Individuals exhibiting so-called disorganized attachment have been found to have parents who display both frightened and frightening responses. 

In a sense, rage and panic are both communicated to and conditioned within the offspring of such parents. According to attachment researcher Mary Main, if parenting generates multiple, contradictory models of attachment, this creates a sense of insecurity in the offspring.

Complex limbic system reactions to the social environment have been found to be specific to important individuals within the family. Problematic reactions such as rage attacks can be seen to occur with one parent but not the other! If interactions with primary attachment figures are highly stressful over prolonged periods, this can have a profound effect on the development of a child’s brain that last a long, long time.

Early learning may be particularly difficult to inhibit. In general, it is much harder to unlearn fear than to learn it in the first place – a fact highly consistent with the experience of psychotherapists trying to extinguish chronic anxiety, particularly chronic interpersonal anxiety. 

Extinction of fear responses has also been found to be context specific. If a fear response is extinguished in one context, it may come right back if an animal is moved to a somewhat different environment. If the new environment is similar to another one such as the early family environment, fearful patterns of behavior learned early in life but inappropriate for the new environment may therefore be seen.

So, early influences are very powerful, but that does not mean that later experiences are inconsequential. When individuals grow up, their parents usually continue to act in ways that recapitulate social interactional sequences from the patient's early life experience. This parental behavior automatically both cues and reinforces old but engrained role relationship schemata (mental models of how to respond to different social cues).  

In turn, these reinforced schemata become more likely to be activated in the patient's current social interactions. This leads to reenactment and recapitulation of these patterns in other relationships. This is the basis of what Freud referred to as the repetition compulsion.

As I have described, parental behavior seems to be an extremely potent environmental trigger for previously learned social behavior. This most likely stems from the survival value of coherent group structure in evolution. As psychoanalysts have hypothesized, children internalize the values and role behaviors of their social system, and conformity to the group has in the past continued to have survival value throughout the life cycle.  

Parental behavior has such a powerful effect in triggering old schemata that it does not have to occur with any great degree of frequency in order for its effects to continue. In adults, the reinforcement of schemata occurs in a manner analogous to the learning theory paradigm of a variable intermittent reinforcement schedule. That is, the powerful parental behavior may be witnessed infrequently but unpredictably, leading the patient to continue to react rigidly in ways consistent with old role-relationship expectations.  

The Limits of Cognitive Psychotherapy

The purveyors of the type of psychotherapy known as cognitive-behavior therapy (CBT), which is currently the predominant psychotherapy paradigm being taught in psychology graduate degree programs, like to claim that their type of therapy is the most "evidenced based" of all psychotherapies and is therefore vastly superior to the more humanistic and relationship-oriented types of psychotherapy. 

It is true that they have more studies than anyone else, but that is because they have very limited treatment goals which are very easy to measure, and they do not study complex people who have a lot of different (comorbid) psychological problems.  Even so, their claims of the superiority of their evidence base are highly inflated.  I go into exactly how in detail in How Dysfunctional Behavior Spurs Mental Disorders. 

It is also true that they control the funding for psychotherapy outcome research and deny the followers of other schools a chance to prove their mettle in randomized clinical trials.  Psychotherapy researchers refer to the "cognitive behavioral mafia" at the National Institute of Mental Health.

One of the major components of CBT is cognitive therapy, first pioneered by psychologist Albert Ellis and then refined by psychiatrist Aaron Beck.  Cognitive therapy is based on the idea that human beings are fundamentally irrational creatures in that they make a lot of logical errors whenever they assess the risks and benefits of various situations and courses of behavior.  These irrational ideas then lead to out of control emotions like unreasonable anger and depression.

Albert Ellis

 Ellis speaks of people "depressing themselves" with worst case scenarios (catastrophizing), or by drawing broad conclusions from single examples (e.g., "Since I failed this test, I'll fail all the ones in the future" - overgeneralizing), or by setting up absurdly high standards for themselves with a lot of musts and shoulds.  He liked to call this last one "shoulding all over yourself."

Aaron Beck

Cognitive therapy is designed to employ something called collaborative empiricism.  The patient and therapist get together to discuss the logical fallacies in some of the patient's thinking and to objectively examine the "evidence" for his or her beliefs.  If the individual can become more of an objective, empirical, scientific type, he or she will not experience chronically negative emotional states - or so the reasoning goes.

A current and popular version of cognitive therapy is called Acceptance and Commitment Therapy (ACT).  At slight risk of oversimplifying this therapy, it consists almost entirely of trying to teach people that they do not have to believe everything that they think.

It's interesting that when CBT therapists start to deal with more significant self-destructive behavior, such as that seen in personality disorders, then what they do starts to look a lot more like what humanistic or relationship-oriented psychotherapists do.  IMO, one big reason for this is the existence of certain types of beliefs that human beings tend to hang on to as if their lives depended on it, notwithstanding even the most obvious evidence to the contrary. 

This type of belief was first identified by psychoanalytic pioneer Karen Horney.  She referred to them as positive value blockages, for reasons I will describe shortly.  They are held by individuals.  Later on, family systems therapists noted a similar phenomenon at the level of the kin or family group.  They called these collectively held notions family myths.  Of course, dogmatic myths are also seen at the level of the subculture, where one might refer to them as theology.

Karen Horney

Try to challenge these beliefs, and in response you get a version of," My mind is made up; don't confuse me with the facts." Trying to challenge the rationality of positive value blocks or family myths using cognitive therapy is like trying to convince a Birther that President Obama was born in Hawaii.

Horney's idea of positive value blocks, which she conceptualized as defense mechanisms, is tied to the idea of a false self, which also called a persona.  Children growing up in dysfunctional families who are subjected to rejection, brutality, withering criticism, ridicule, and/or hostile control will feel safer when they act in certain ways which are rewarded by the family environment, but which may run counter to the way they really feel deep down inside of them.  The different sorts of behavior that fill this bill leads them to develop certain character types. 

According to Horney, when such children - and later when they become adults - act in these ways, they often pretend to be proud of their behavior, but deep down they feel alienated from themselves and full of self-hatred.  This neurotic or conflictual pride is a glorification of a phony self.  This false pride is usually supported with a number of ideas which justify the character type.  These ideas often take the form of proverbs or slogans such as, "Nice guys finish last."  Such ideas act as blocks to the expression of a person's true self (which might wish to be nice), and this is what is meant by the term positive value blockages.

An individual's family often not only shares these beliefs, but lives by them.  Some beliefs can be specific to certain individuals within the family (for example, what one family member is "really" like and who within the family he or she is closest to), while others apply to everyone.  The ideas in this context are what is referred to as family myths.  They justify and support a set of rules which dictate how each family member should behave, and what family roles each must fully and compulsively play, in order for the family to function in a predictable way (family homeostasis). 

The myths function as a belief system which the family uses, often defensively, to explain its experience to itself.  They are sometimes not verbalized explicitly so as to avoid any challenges to them. They can be taught implicitly through various forms of acting out and family rituals.  However, they may also take the form of oft-verbalized adages just like positive value blockages do in individuals. 

I had one patient who justified never trying to change a bad situation with three different proverbs:  "the grass is always greener on the other side," "the devil you know is better than the devil you don't know," and "you've made your bed so now you have to lie in it."  All three slogans had been repeated to her ad nauseam by her parents when she was growing up.

Therapists, challenge these ideas without understanding how central they are to a person's psychology at your own risk.  Your patient will fight you tooth and nail, and you will get absolutely nowhere. Cognitive therapists, put that in your pipe and smoke it.  Or is that just another family myth?