The Pervasive Weaknesses of Psychotherapy Studies

A psychiatrist with Intense, bulging eyes by C. Josef, CC Attributions 4.0

 

In my last post, I mentioned that the research into both psychotherapy outcomes and personality disorders is extremely weak, and even that characterization may even be giving it too much credit. Extensive clinical experience has been dismissed as “anecdotal,” even when therapists see the same things over and over again and their observations are confirmed by many other therapists who actually look at the same phenomena.

The irony here is that almost ALL of the “research” data in these two areas is a collection of anecdotes, since they are entirely based on patient self-report or the experimenters’ personal observations – all of which are subject to significant bias. We cannot read minds and people act and lie a lot, and a lot of other influences on the “data” are extant and unknown to the researchers.

Most psychotherapy outcome studies are characterized by frequent patient drop-outs and by the fact that a significant portion of the study subjects do not respond to the treatment being offered. And outcome measures in these studies are typically the relief of symptoms, not changes in the patient’s abilities to love, work, and play successfully. And the subjects are rarely followed up for a significant period of time to see if any results that are attained last. A significant portion of the study “gains” are often lost after a year or so.

There are over 200 different models for understanding psychopathology and doing psychotherapy, although most are variations of the five major models: psychodynamic, cognitive, behavioral, affect focused, and family systems. Most therapists borrow techniques from schools other than the one they were trained  in.

When results from several different studies using different schools are compared, most tend to come out with about the same success rates. In the beginning of a movement to try to integrate the different schools, this was known jokingly as the Dodo Bird verdict (after a character in Alice in Wonderland) – all have won and all must have prizes. And when two schools are compared in a single study, the school of person who is the lead author of the study comes out the winner in 85% of them (an allegiance effect). Bias, anyone?

Even then, when a certain percentage of the study subjects did respond to the “inferior” treatment, we don’t know whether or not they would have done well in the “better” treatment. Or if those who did not respond to the “better” one would have responded to the other treatment.

Over the years I have posted critiques of the “research” and in this post will summarize a bunch more of the points I made. If there is a whole post about them, I’ll include a link to the original.

A big one I mentioned in the last post: when a school of therapy is evaluated, the individual interventions which comprise them (of which there are quite a few) usually are not, so we don’t know which of them worked and which of them did not or were even counterproductive. Responses to the individual interventions are important to know about because, despite the use of treatment manuals supposedly insuring that all therapists in a study using a specific school are doing the same things, this is not possible. Subjects all respond differently to a given intervention. Therapists have to pick and choose which intervention will be used next. Also differing - with significant impact - is the way the intervention is presented: phrasing, body language, tone of voice etc.

Another major study weakness: Those that try to apportion causation of psychological behavioral syndromes to genetic vs. environmental influences use studies of twins raised apart. This type of study routinely over-estimates genetic contributions by assuming parents treat all their children alike, which is way off. Furthermore, they are looking at the end result of gene and environmental interaction (phenotype, not genotype) without any way to know how much of a given finding to apportion to each of them.

Most psychotherapy outcome studies exclude patients with more than one disorder, although a high percentage of patients have co-morbid affective and anxiety disorders as well as more than one personality disorder. The therapy will of course look more effective if you include only the easiest patients.

In studies of psychiatric symptoms which may occur in response to stress, reactions are evaluated without any reference to what the actual stresses were to which the subjects were responding. 

Confusion between correlation and causation is illustrated in such studies as those that attempt to determine the causes or the results of drug abuse. For example: Does marijuana cause poor school performance or the other way around - or is there actually a third factor which leads to both of them?

Differences in brain area size and functioning between different groups on fMRI scans are automatically interpreted as abnormalities. In fact, most differences are due to normal neural plasticity in response to changes in the environment.

In studying  the nature of the relationship between parents and children, No one can  precisely measure the nature of the relationship. These relationships are not constants but vary across time and situational contexts. Parents might be good disciplinarians when it comes to providing children with adequate curfews, for example, but terrible at allowing them to stay up all hours of the night. Furthermore, the disciplinary practices certainly change over time as the children get older. Second, how does a study even attempt to measure the tone of parenting practices? Third, oftentimes studies are based on parent self report. If a mother were abusive or inconsistent, how likely do these authors think she would admit to it, even if she were very self-aware, which obviously many people are not.

In some Cognitive Behavioral Therapy outcome sudies, therapy  is at times compared with "treatment as usual" —letting subjects get whatever other treatments outside of the study treatment that they chose to have, allowing good therapists and bad therapists, and good therapies and bad therapies, to essentially cancel each other out. Even so, the sizes of treatment effects are only small to moderate.  “Response” just meant there was some significant improvement in symptoms, not that the symptoms of the disorders actually went away. Rates for actual remission from the disorders were even smaller. A considerable proportion of study patients do not sufficiently benefit from CBT.

In epidemiological research into environmental risk factors for various psychiatric disorders, most studies try to measure the effect of a single environmental exposure on a single outcome—something that rarely exists in the real world. Individuals are exposed to environmental elements as they accumulate over time, so that one single exposure usually means very little. Exposure also is “dynamic, interactive, and intertwined" with various other domains including those internal to individuals, what individuals do within various contexts, and the external environment itself—which is constantly changing. Last but not least, each individual attributes a different, and sometimes changing, psychological meaning to everything that happens to them.

The difference between “cannot” and “do not:” Study are often characterized by lack of attention to subject motivation, and ignorance of the concept of “false self.” In one study, high-psychopathy participants showed atypical, significantly reduced neural responses in the brain on an fMRI to negatively-toned pictures under passive viewing conditions. However, this effect seemed to disappear when the subjects were instructed to try to maximize their naturally occurring emotional reactions to these same pictures!

Researchers mistake a high index of suspicion for an “inability” to correctly read the mental states of others.

Studies show that changing a parent’s behavior towards BPD children can make those with BPD better—but seem to ignore the possibility that their behavior apparently helped cause the disorder in the first place.

The Canceling of the American Psychotherapist

 

In my review of the book, The Coddling of the American Mind by Haidt and Lukianoff, I focused on a cultural shift on college campuses that has often led to an environment characterized by political correctness rather than free and open debate between opposing viewpoints. Groups have even turned on their own members for deviating ever so slightly from a “party line.” I discussed how this is one way that groupthink can manifest itself.

A  new book by Lukianoff and Schlot talks about how this situation has apparently gotten much worse, and has spread to other educational institutions and vocational venues such as journalism.

One of the most problematic ideas of groupthink on campuses has to do with the so-called Diversity, Equity and Inclusion (DEI) philosophy. Of course, diversity, equality (of opportunity, not of outcome), and inclusiveness are virtuous and wonderful things when applied to individuals with all of their family and historical influences and experiences. Unfortunately, this has now morphed into defining people entirely by their ethnic group. Members of groups are either ALL victims (ALL black people) or ALL oppressors because they may have benefitted in some  way from their “advantages” (ALL white people). 

Apparently except for Jews, who have been just about the most oppressed group for the longest time over history but also somehow counted some of the world's most successful people among their numbers. This obvious rebuttal to “Critical Theory” has been solved by some people by seeing Jews as White colonialists, while by others seeing them as Colored. Whichever is convenient. These people are still trying to figure out how to classify Asian Americans who aren’t white but who are who also more successful on average than other American groups.

This is in fact exactly the opposite of what Martin Luthor King preached! He spoke of judging people by the content of their character and not by the color of their skin.

But no matter. The primary reason that I am reviewing this book is because this type of thinking has now spread to psychotherapy teaching programs! Your problems all now seem to originate, not from your family or personality or genetics, but from the fact that you are either an oppressor or a victim, according to your group identity, and you need to admit it! As the authors say, “It’s not about your problems. You are the problem.”  

Everything wrong with people is seen through this lens. Therapists are now lecturing patients who have “incorrect” political views. “Multicultural and social justice counseling competencies” has even been endorsed by the American Counseling Association. The American Psychological Association is beginning to follow suit. They endorse, for instance, the idea that the repression of feelings of males typically seen in many cultures (who, say, won’t cry), often modeled by parents, is an example of traditional masculinity invariably being “toxic.”

The authors of the Cancelling book believe that these approaches are counterproductive. They can cause patients to see themselves only as helpless victims, and discourage people who are automatically assumed to be perpetrators from seeking help. How do these therapists reconcile themselves to the fact that, in 2020, 70% of completed suicides were “privileged” white males (according to the American Suicide Foundation).

When I first read the chapter about psychology programs I was a little unsure how common this was, since I hadn't heard about it. But then I saw an advertisement for a book for therapists in the Psychotherapy Networker magazine. It was called Decolonizing Therapy by a PsyD named Jennifer Mullan. I quote from the ad: "Ignoring collective global trauma makes delivering effective therapy impossible; not knowing how to interrogate privilege (as a therapist, client, or both), and shying away from understanding how we may be participating in oppression is irresponsible." 

Well, I do believe a therapist has to understand what each family may have experienced in this regard to understand certain shared intrapsychic conflicts that are seen within a given family - but each family is unique. And hopefully the therapist is not acting out blatantly racist attitudes. To assume all white therapists are doing this is what is irresponsible.

Anyone who disagrees in some graduate programs is in high danger of being “cancelled” by fellow students. One student said the environment was so mean that a student who lost a family member to COVID was afraid to tell anyone lest they be told that they were crying “white tears” and lectured about how people of color were the real victims of the pandemic!

Now of course it is true that many people have been severely traumatized  by racial or group experiences and that such trauma can lead to psychopathology, but that is not the same as saying that other factors might not be equally or even more important.

This is a perfect example of one key feature of Groupthink: either/or or black and white thinking. No context, no subtlety. I recently had a negative personal experience with that type of thinking with psychology interns I used to lecture to. This one didn’t involve oppressors vs. victims, but there was a certain similarity in its misclassification scheme. And it’s something brand new.

I used to lecture them about borderline personality disorder (BPD). The interns came from the University of Tennessee Health Science center and another group of interns from the Memphis VA. Now admittedly I did discuss some of my own, outside-the-mainstream ideas, but I also discussed other current psychotherapy paradigms and theories about the disorder. 

After I retired, I was still invited back every year to give the talk. Then suddenly the person in charge who called me to do this stopped calling. It took me two or three years to find out why, but I finally was able to corner her. First the VA, and then the UT interns said they no longer wanted lectures about doctor’s individual practice experiences (mine was over 35 years), but only from people who did literature reviews or active researchers! 

This same type of thing was happening on my Psychology Today blog. One post I wrote was rejected because, they said, it was an opinion piece not based on research - when most of their posts are NOT research based. They just, for the first time in years, didn't like my opinion. So I stopped posting.

As readers of my blogs know, the literature in both psychotherapy and BPD is weak - and that's being generous. It is characterized by false assumptions, the fact that whole schools of therapy are evaluated but not the individual interventions which comprise them, the ignoring of many obvious impacting factors, and clinically-useless correlations between certain symptoms within one diagnoses or between two of them. People with a lot of clinical experiences in this area are a hell of a lot more knowledgeable than researchers. 

The interns even wanted solely literature-based reviews a about the treatment of transgendered patients, which has barely begun as a subject for any studies at all!

If a therapist is more interested in politics and your ethnic group than in you, drop them ASAP and find another therapist.

Different Schools of Thought in Psychotherapy

At last count, there were over 200 different "schools" of psychotherapy, each with its own ideas about why people act in self-defeating ways or in ways which bring them emotional or even physical pain, and how to help them to stop. Of course psychotherapy is, despite having been around for a hundred years, a young science, but our field is more difficult to study “empirically” than any other. 

The problems we have are enormous because we cannot read minds, and people can choose to some extent how they react to any therapy intervention. Patients withhold information about their situations from therapists all the time due to protecting their families from negative judgments, guilt, shame, or a concern the therapist might not be interested in it.

In psychotherapy outcome studies, seemingly minor variations in therapist techniques that are in fact vitally important (such as body language and tone of voice) aren’t even measured. There are no good active control treatments, and, when two therapies are compared,  the therapy method favored by the first author of the study comes out ahead 85% of the time due to the authors’ biases (allegiance effects). 

We cannot do double blinding because that would mean the therapists wouldn’t know what they were doing, which would not be a good test of the treatment. And of course once again there can be a major lack of complete candor by subjects. Much of the study results are based on patient self report, a notoriously unreliable method of data collection. And there is no way to distinguish an act patients may be playing for their family of origin (a false self or persona) from their real beliefs and feelings, or performance from ability.

The ecological fallacy – thinking all patients with a particular disorder react exactly like an average patient - is rampant in the literature. If 20 % of clients with a particular problem respond to one intervention and 40% respond to a second one, this does not mean that the second one is better for everyone than the first. The 20% who responded to the first one could actually get worse with the second one.

There is also a huge and highly problematic groupthink problem in the psychotherapy field, with purveyors of various schools claiming a monopoly on truth. Often the need for ideological purity, the admiration for an academic leader within a hierarchy, or the profit motive causes science to take a back seat in favor of a group's other interests. 

Fallacious arguments ensue. One of the most common is that entire complex groups of theoretical constructs that characterize a given school are rejected in total by another school, as if, if one theoretical part of a school is wrong, the whole thing must be wrong. Psychoanalysis may have been wrong about penis envy, for example, but dismissing intrapsychic conflict entirely as a construct because of that is - in a word - stupid.

Another is that a phenomena that two schools are looking at but explain differently are just being called different names and are given different explanations, which are then accepted by a given school as gospel without even a thought to investigating other possible explanations. I recently wrote in a post about how both the cognitive-behaviorists' "irrational thoughts" and the psychoanalyst's "defense mechanisms" probably serve the same purpose, but that neither school explains that purpose with reference to group dynamics - IMO the key factor.

There is still hope. IMO we have to look for recurring patterns in our therapy patients (not in research subjects, because contact is minimal) as well as within their social milieu. At times, we have to meet with clients along with their significant others in order to get a more well-rounded picture. We have to do so in long-term psychotherapy, because it takes quite a while for the whole story to unfold. 

We should do this in order to figure out commonalities and in order to figure out what questions to ask. In particular, we should look for evidence of motivated reasoning in what our clients report – logical fallacies, inconsistencies and contradictions (sometimes voiced months apart – the importance of extensive therapy notes cannot be overestimated), and defensive reactions. If handled well, this will help us unearth what clients may be trying to hide from us. 

Doing so also suggests questions we may have not thought to ask, or pay attention to environmental variables we were not even aware of that turn out to be major contributing factors to psychopathology that demand attention.

Research In Psychotherapy: Outcome Research Versus Process Research

In my Psychology Today blogpost about research in psychotherapy outcomes, and in my last book, I complained about the inflated claims of researchers in psychotherapy - particularly those made by purveyors of cognitive-behavioral therapy (CBT). They grossly overstate both the power and the significance of their results.

Unfortunately, a new report by the Institute of Medicine (IOM) falls for this baloney hook, line and sinker. The report on psychosocial interventions for mental illness and substance abuse has drawn a wide variety of responses from the field - including praise, recommendations for improvement, and some sharp criticism from psychiatrists and mental health professionals who are experts on psychotherapy. I am obviously sympathetic to the critics.

Of particular interest is that the report lauds the so-called "evidence-based psychotherapies" - code for those therapies which are "supported" by the incredibly weak psychotherapy outcome studies. One critic, Peter Roy-Byrne, M.D, summed up the criticisms of the report as follows:" In medicine, there is usually an array of different treatments for the same condition because of individual variability that is still poorly understood. Yet the field of medicine does not spend its time trying to understand what are the common elements between various effective treatments, though it will often explore comparative effectiveness as a way of improving care. It may well be that different kinds of individuals and problems demand different psychotherapeutic approaches rather than that there is one elemental Holy Grail that will be best for everyone.”

Of note is that, at least if you believe in free will as I do, patients always can choose to either respond favorably or unfavorably to any intervention a therapist makes. It is just not all that predictable, because everyone can choose to respond differently. In fact, the very same intervention given to seemingly very similar patients can lead to responses that are completely opposite from each other - in one case the patient improves on some dimension, while in the next the patient may get worse! In psychotherapy, patients are very different from one another in ways that vastly outnumber individual differences that affect treatment outcomes in any other field of medicine.

Holly Swartz, M.D., of the Department of Psychiatry at the University of Pittsburgh School of Medicine, brings up another criticism of the IOM report: “The recommendation to reduce highly complex interventions to their component parts, however, is misguided. A bias toward CBT and CBT-based interventions constitutes an essential flaw in the IOM report, placing affect-focused therapies such as IPT (interpersonal therapy) at risk for unfair negative evaluation and, ultimately, elimination from our therapeutic armamentarium. … [T]he IOM report should advance an inclusive research agenda that reflects and supports the diversity of psychosocial interventions that the IOM purports to represent.”

Yet another problem with the IOM report and similar viewpoints is that they completely ignore the fact that there is a vast literature within psychotherapy research that does not focus on outcomes but on process. Process research looks at the moment to moment interactions of patients and therapists within the context of their particular relationship.

As Les Greenberg, Ph.D, puts it, "Research on change processes is needed to help explain how psychotherapy produces change. To explain processes of change it will be important to measure three types of outcomes—immediate, intermediate, and final—and three levels of process—speech act, episode, and relationship. Emphasis will need to be placed on specifying different types of in-session change episodes and the intermediate outcomes they produce. The assumption that all processes have the same meaning (regardless of context) needs to be dropped, and a context-sensitive process research needs to be developed. Speech acts need to be viewed in the context of the types of episodes in which they occur, and episodes need to be viewed in the context of the type of relationship in which they occur.

Speech acts refers to the fact that speech does not merely convey information to, or exchange propositions with, a listener. Sentences do things that are frequently independent of the meaning of the actual words that are used. Speech causes others to perform acts. If I say, "I hear you're having a party Saturday," I am not describing only my recent experience of having heard about the party. I am probably fishing for an actual invitation. In all likelihood, I have made in advance a determination that this sort of statement is the best way to accomplish my goal of attend­ing the party. I have made a prediction about the future behavior of the listener. If this particular ploy leads to no response or a different response, I will consider alternative strategies.

Those who tout psychotherapy outcome studies, which study psychotherapy interventions as if they occurred in some sort of relationship vacuum devoid of context, seem to want to pretend that the highly significant process research literature does not even exist. In fact, the vast majority of articles published in the journal Psychiatric Research are process studies, not outcome studies.

Some Great Quotable Quotes from People Who Agree with Me About Stuff - Part I

Some people just naturally have a way with words, and succinctly summarize ideas using comments that I wish I had come up with. 

Today's post, the first of a series of two, contains some of my favorite recent quotes that center around themes discussed in this blog. Many of them come from three of my favorite sources of great quotes: advice columnist Carolyn Hax, parenting advisor John Rosemond, and fellow blogger George Dawson.

Of course, the authors of these quotes and I do not agree about many other things, but so what?

I have been collecting the quotes and putting them on my Facebook fan page at http://www.facebook.com/pages/David-M-Allen-MD/80658565761?fref=ts. The ones contained in this post and the next started in January of 2014, and are loosely organized by topic.

You may find a hidden joke or two among the mayhem.

Psychiatric and Psychotherapy Research

"A significant p value does not specify the probability that the same result can be reproduced in another study." ~ Prof. Gerd Gigerenzer, Max Planck Institute for Human Development.

"If being cited [as a reference in another published study] meant being read, citation statistics might well be a useful criterion. Yet a study estimated that of the articles cited, only 20% had actually been read... For instance, the most important publication in 20th-century biology, Watson and Crick’s paper on the double helix, was rarely cited in the first 10 years after its publication. Innovative ideas take time to be appreciated."
       ~ Prof. Gerd Gigerenzer

It's all in how you look at it, Department:

Medscape News Story about a Study: "Individuals with a neurotic personality type may have reduced brain plasticity during the performance of working memory tasks that may affect their ability to store memories, say US researchers in findings that show the opposite effect in people with a conscientious personality."

         Said one commenter in response: "It is nice to have documentation what those of us who have hired office help have known for years. Personnel with personal problems that occupies their minds continuously are unable to perform satisfactorily in the office."

" I have lost count of the number of papers [that "study" what is supposed to be major depressive disorder] I have read where the depression rating scores were what I consider to be low to trivial." ~ George Dawson, M.D.

In a PTSD study comparing CBT to psychodynamic therapy: "The so-called psychodynamic therapists were also forbidden to discuss the trauma that brought the patient to treatment. Imagine that—you come to treatment for PTSD because you have experienced a traumatic event, and your therapist is forbidden from discussing it with you. When patients brought up the trauma, the therapists were instructed to change the topic." ~ Jonathan Shedler, Ph.D. 

"Evidence based data' is suggestive but typically based on group data, hence only suggestive when working with a single patient. Other sources of suggestions are also available." ~ Thad Harshbarger, Ph.D.  

"The notion that biological changes going on during early adolescence predispose the young teen to all manner of difficult behavior is a myth belied historically, cross-culturally, and by the fact that plenty of young teens are respectful, obedient, and hard-working. That last fact is conclusive evidence to the effect that despite hype to the contrary, there are no changes going on in the young adolescent brain that make inevitable any sort of problematic behavior." ~ John Rosemond, Ph.D.

"When every study reported by a particular group of researchers just happens to reinforce their shared belief system, it makes me skeptical." ~ Loretta Graziano Breuning, Ph.D. 
         Are you listening, CBT and bipolar II researchers?

"Neuroscientist: someone who knows how little we know about the brain." ~ Neuroskeptic

“Maybe sometimes it’s the questions that are biased, not the answers,” ~ John Ioannidis, Ph.D., on bias in medical research - for example,drug companies comparing their new drugs against those already known to be inferior to others on the market.

"Blaming personality disorders on brain pathology due to bad genes is like "blaming badly written software on the hardware." ~ "SwissCheese," who commented on a post on my Psychology Today blog and says he's a computer scientist married to someone with borderline personality disorder.

"The NIMH devotes almost all of its enormous research budget to glamorous, but very long shot, biological research that over the past four decades has contributed exactly nothing to the treatment and lives of the severely [mentally] ill." ~ Allen Frances, M.D.

"The trial result generally depends on rating scale or clinician global rating scale results that grossly oversimplify the condition and measure parameters that are irrelevant in clinical settings. The best example I can think of is depression rating scales that list DSM criteria for depression and then apply a Likert dimension to those symptoms. In clinical practice it is common to see hundreds of patients with the same score on this scale who have a full spectrum of disability from absolutely none to totally disabled. Which population might be more likely to exhibit an antidepressant effect? " ~ Richard Dawson, M.D.

"Published' and ‘true' are not synonyms" ~ Brian Nosek, Ph.D., a psychology professor at the University of Virginia in Charlottesville

"Laboratory studies of social attention have largely focused on the extraction of social information from images (e.g., photos and videos). However, in the natural world attending to real people involves both the reading of social cues and the sending of social signals. ... the influence of another individual on human behaviour is so pronounced that the implied social presence of another person is enough to have a profound effect on where people look, what they say and do, and even modify their willingness to cheat or to engage in prosocial behaviours." ~ Alan Kingstone, Ph.D.

"The hypothalamus is involved in the body's centrally important "Four F's:" fight, flight, feeding, and sex." ~ Otto Kernberg, M.D.

"No man should escape our universities without knowing how little he knows." ~ J. Robert Oppenheimer

"The biggest misconception here seems to be that patients are accurate reporters and they have no unconscious agenda." ~ George Dawson, M.D.

Relationships

"No one can help you if you’d rather be safe than brave.” ~ Carolyn Hax

"Hiding how you feel is how love dies. You think he backed the wrong horse here? Then say so. A grown-up won’t make you pay." ~ Carolyn Hax

"You want a spouse who wants to meet your needs, as part of a commitment to mutual support." ~ Carolyn Hax

What to say to a spouse who refuses to see a marriage counselor when you request it, because he or she doesn't have a problem, it's all just you: "But you do have a problem: Your marriage is in trouble." ~ Annie's Mailbox

"You either aren’t up to this challenge or you don’t want to be, and that’s all you need to know, because choosing a life partner isn’t about being open-minded or fair or noble. It isn’t just about loving or being in love, either. It’s about an unflinching estimation of what works." ~ Carolyn Hax

"One problem that recurs more and more frequently these days, in books and plays and movies, is the inability of people to communicate with the people they love: husbands and wives who can't communicate, children who can't communicate with their parents, and so on. And the characters in these books and plays and so on, and in real life, I might add, spend hours bemoaning the fact that they can't communicate. I feel that if a person can't communicate, the very least he can do is to shut up." ~ Tom Lehrer

"If people are determined to be insulted, they will find a way to be insulted." ~ Amy Dickinson

Parenting

"An adult who enters into a power struggle with a child is no longer acting like an authority figure; therefore, the only person with any power in an adult-child power struggle is the child." ~ John Rosemond, Ph.D.

Letter to advice columnist Carolyn Hax: I am happy he is sharing his interests (in rap music) with me and I have explained to him my perspective that the material makes me uneasy for all of the above reasons. His interest continues unabated. Do I set certain limits on what he can listen to (he is 14) or do I just let it be and hope he grows out of it?

          Ms. Hax's answer: You omitted (c) Raise him, then trust him, to be one of the millions of people who are able to distinguish between an art form and an instruction manual for the treatment of others.

"I, too, am skeptical of the 'Oh you’ll love them when they’re yours' line. Some people regret having kids and just know they can’t say that out loud, and I’d wager there’s a bigger population who don’t even let themselves think that." ~ Carolyn Hax

"Helicopter parenting now seems to have blossumed into Apache Blackhawk parenting." - John Rosemond, Ph.D.

"Parents help their kids with homework, often downright doing it for them; they help their kids study for tests; and they demand of educators that their kids’ school experience be immaculate. I don’t believe that pouring more money into education has worked or is going to work, but I do believe that teachers should be duly compensated for putting up with this garbage. " ~ John Rosemond, Ph.D.

"Parents who are not on the same parenting page will not get on the same page by regarding and treating their differences as a parenting problem. It's a marital problem." ~ John Rosemond, Ph.D.

To be continued.....