Monthly Archives: May 2010

Parataxic Distortion

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My favorite new term from my family therapy program is parataxic distortion, coined by the “American Freud” and one of the grandfathers of family therapy, Harry Stack Sullivan.

A parataxic distortion is when a current situation or person reminds you of something from your past, often without you knowing it, such that you behave to some degree as if you are inyour past, dealing with that situation or person. Parataxic distortion is an umbrella term for confusions like Freud’s transference (client gets inappropriately emotional about therapist) and countertransference (therapist gets inappropriately emotional about client). It is also very much like to co-counseling’s “restimulation of distress.” Most likely every psychotherapeutic school has its own name for this phenomenon.

The idea is that there is a way in which your memories are categorical, not specific. That is, if your dad hit you when you were a kid, you not only attach fear and anger to your dad in your memory, you also attach it to a range of things, maybe bald men, short men, men in general, authority figures in general, certain kinds of places or rooms, etc.

Mostly, our memories are useful. This ability to generalize, for example, helps us avoid burning ourselves on hot stoves in general instead of having to painfully learn not to touch each hot stove. Neat trick!

But with a parataxic distortion, our unconscious memory keeps us from being able to understand and deal with situations as they are, in the present. It patterns your behavior. It limits your options. Usually without your knowing it, it makes your life more scary, sad, irritating, and ultimately isolated than it needs to be. Most therapeutic modalities have some version of this three-stage recipe for resolving parataxic distortions: 1) Form a trusting relationship with someone who has less distortion in the area you have trouble with. 2) Have a “corrective emotional experience,” where you basically re-experience your distortion-driven emotional pattern while demonstrably safe in this trusting relationship. 3) Have a “cognitive reappraisal,” meaning come to a new understanding of your behavior in light of current reality as it is. Go meta.

Easier said than done, of course, but well worth it!

[First published on Nathen’s Miraculous Escape, May 13, 2010.]

The Adverse Childhood Experiences Study

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I’m learning about child abuse and neglect in my Child and Family Assessment class. Today I read about the ACE study, by the US Center for Disease Control. It is a huge study, with over 17,000 participants, where they gathered information about childhood abuse, neglect, and household dysfunction, and then proceeded to see what health outcomes and behaviors they could predict with that information. It turns out they can predict a lot. They’ve published 50 articles on the study and the research is ongoing–they are continuing to collect health information as the participants in the study age. I’ll present a few of their findings below. For more, see the ACE Study.

Here are some of their findings. I’ll paste in the definitions of the categories of adverse childhood experiences below. Strong correlations were found with the following:

  • alcoholism and alcohol abuse (4 or more categories of ACE meant 4-12 times increase)
  • chronic obstructive pulmonary disease (that is, lung disease)
  • depression (4 or more categories of ACE meant 4-12 times increase)
  • fetal death
  • health-related quality of life (way more inactivity, severe obesity, bone fractures)
  • illicit drug use
  • ischemic heart disease (IHD)
  • liver disease
  • risk for intimate partner violence
  • multiple sexual partners (4 or more categories of ACE correlated with 50 or more sexual partners)
  • sexually transmitted diseases (STDs) (4 or more categories of ACE meant 4-12 times increase)
  • smoking
  • suicide attempts (4 or more categories of ACE meant 4-12 times increase)
  • unintended pregnancies

Here are the kinds of abuse, neglect, and dysfunction they asked about, quoted from the site:

Abuse

Emotional Abuse:
Often or very often a parent or other adult in the household swore at you, insulted you, or put you down and/or sometimes, often or very often acted in a way that made you think that you might be physically hurt.

Physical Abuse:
Sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at you and/or ever hit so hard that you had marks or were injured.

Sexual Abuse:
An adult or person at least 5 years older ever touched or fondled you in a sexual way, and/or had you touch their body in a sexual way, and/or attempted oral, anal, or vaginal intercourse with you and/or actually had oral, anal, or vaginal intercourse with you.

Neglect

Emotional Neglect1

Respondents were asked whether their family made them feel special, loved, and if their family was a source of strength, support, and protection. Emotional neglect was defined using scale scores that represent moderate to extreme exposure on the Emotional Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form.

Physical Neglect1

Respondents were asked whether there was enough to eat, if their parents drinking interfered with their care, if they ever wore dirty clothes, and if there was someone to take them to the doctor. Physical neglect was defined using scale scores that represent moderate to extreme exposure on the Physical Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form constituted physical neglect.

Household Dysfunction

Mother Treated Violently:
Your mother or stepmother was sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her and/or sometimes often, or very often kicked, bitten, hit with a fist, or hit with something hard, and/or ever repeatedly hit over at least a few minutes and/or ever threatened or hurt by a knife or gun.

Household Substance Abuse:
Lived with anyone who was a problem drinker or alcoholic and/or lived with anyone who used street drugs.

Household Mental Illness:
A household member was depressed or mentally ill and/or a household member attempted suicide.

Parental Separation or Divorce:
Parents were ever separated or divorced.

Incarcerated Household Member:
A household member went to prison.

[First published on Nathen’s Miraculous Escape, May 9, 2010.]

Assessing Sexual or Physical Abuse

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Another unfortunately common situation I will have to assess for in the families I see (in addition to drug & alcohol abuse, domestic violence and many other things) is sexual or physical abuse. One of my texts (Patterson’s Essential Skills in Family Therapy: From the First Interview to Termination) estimates that 1 in 5 women and 1 in 9 men were sexually abused as kids. My other practicum text, Brock & Barnard’s Procedures in Marriage and Family Therapy, gives this list of indicators of abuse(p. 52):

The presence of an alcoholic parent

The family with poor mother-daughter connections/bonds

A mother who is very dependent either psychologically or physically as the result of illness or accident

A father who appears to be very controlling and possessive of his daughter(s)

An acting-out adolescent girl engaging in sexual promiscuity or suicidal gestures who is a frequent runaway or drug abuser

A child who appears to be very overresponsible and parentified in the family context

[First posted on Nathen’s Miraculous Escape, May 5, 2010.]

Diagnostic Criteria for Conduct Disorder

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[First posted on Nathen’s Miraculous Escape]

This is another DSM-IV-TR Mental Disorder diagnosis that is commonly given to children. The DSM says that its prevelence has been increasing for a few decades now and that up to 10% of kids, mostly boys in “urban settings”, have it. It’s a pretty serious label to give a kid. It’s linked with suicide, homicide, various criminal acts, and is thought of as a precursor to Antisocial Personality Disorder. Here are the criteria, quoted word-for-word from the DSM-IV-TR (pp. 98-99):

Diagnostic criteria for Conduct Disorder

A. A repetitive and persistent pattern of behavior in which the basioc rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months.

Aggression to people and animals

(1) often bullies, threatens, or intimidates others

(2) often initiates physical fights

(3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)

(4) has been physically cruel to people

(5) has been physically cruel to animals

(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)

(7) has forced someone into sexual activity

Destruction of property

(8) has deliberately engaged in fire setting with the intention of causing serious damage

(9) has deliberately destroyed others’ property (other than by fire setting)

Deceitfulness or theft

(10) has broken into someone else’s house, building, or car

(11) often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)

(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)

Serious violations of rules

(13) often stays out at night despite parental prohibitions, beginning before age 13 years

(14) has run away from home overnight at least twice while living in parental or parental surrogate (or once without returning for a lengthy period)

(15) is often truant from school, beginning before age 13 years

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

Code based on age at onset:

312.81 Conduct Disorder, Childhood-Onset Type: onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years

312.82 Conduct Disorder, Adolescent-Onset Type: absence of any criteria characteristic of Conduct Disorder prior to age 10 years

312.89 Donduct Disorder, Unspecified Onset: age at onset is not known

Specify severity:

Mild: few if any conduct problems in excess of those required to make the diagnosis andconduct problems cause only minor harm to others

Moderate: number of conduct problems and effect on other intermediate between “mild” and “severe”

Severe: many conduct problems in excess of those required in excess of those required to make the diagnosis or conduct problems cause considerable harm to others

Predictors of Divorce, According to Elizabeth Gilbert

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[First posted on Nathen’s Miraculous Escape, May 3, 2010.]

Elizabeth Gilbert, in her book about marriage, Commitment, lays out her interpretation of a Rutgers report on divorce statistics. Here’s her list of things that correlate with divorce, in the order she mentions them. She lays them out with a lot more subtlety, humor, and personality, but read the book if you want that.

Your parents are divorced

You are alcoholic

You are mentally ill

You cheat on your spouse

You gamble compulsively

You are violent

You are younger than 25

You have not gone to college (especially the woman)

You have children

You lived with your spouse before marriage

You have different racial backgrounds

You are different ages

You have different religions

You have different ethnic backgrounds

You have different cultural backgrounds

You have different careers

You don’t know your neighbors

You don’t belong to social clubs

You don’t live near your families

You are not religious

The man does not do housework

Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

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[First posted on Nathen’s Miraculous Escape, May 1, 2010.]

The DSM-IV-TR reports a prevalence of 3-7% for the famous AD/HD, depending, somewhat cryptically, on “the population sampled and the method of ascertainment” (p. 90). AD/HD is a shoe-in for medication in the minds of most mental health professionals. Children have been treated for this Disorder with stimulants since 1937. We still do not know for certain, however, what the effects are on adults who took stimulants as children. We do know that AD/HD tends to go away during adolescence.

Here are the diagnostic criteria, straight from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Note that criterion C is an attempt to make sure that the troublesome behavior is not just a reaction to one situation, like school–you shouldn’t be diagnosed AD/HD based on behavior that only happens at school, or just at home. That would be something else going on. Note also that, according to the “coding note” at the bottom that once you have this diagnosis, unless you have none of these symptoms, you will always be considered AD/HD “in partial remission.” One last note: I notice in reading literature referring to this Disorder that it is usually referred to as ADD/ADHD. I don’t know why this is, as there is no “Attention Deficit Disorder” in the DSM-IV-TR. Perhaps there was in earlier editions.

Diagnostic criteria for Attention-Deficit/Hyperactivity Disorder

A. Either (1) or (2):

(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Inattention

(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

(b) often has difficulty sustaining attention in tasks or play activities

(c) often does not seem to listen when spoken to directly

(d) often does not follow through on instructions and fails to finish school-work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

(e) often has difficulty organizing tasks and activities

(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)

(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

(h) is often easily distracted by extraneous stimuli

(i) is often forgetful in daily activities

(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with development level:

Hyperactivity

(a) often fidgets with hands or feet or squirms in seat

(b) often leaves seat in classroom or in other situations in which remaining seated is expected

(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

(d) often has difficulty playing or engaging in leisure activities quietly

(e) is often “on the go” or often acts as if “driven by a motor”

(f) often talks excessively

Impulsivity

(g) often blurts out answers before questions have been completed

(h) often has difficulty awaiting turn

(i) often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (e.g., at shool [or work] and at home).

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Code based on type:

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months

314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type:if Criterion A1 is met but Criterion A2 is not met for the past 6 months

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months

Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, “In Partial Remission” should be specified.

Diagnosis

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I read the following, by Steven Wolin, in Froma Walsh’s Spiritual Resources in Family Therapy, and it brought tears to my eyes. The “DSM” he mentions is the Diagnostic and Statistical Manual of Mental Disorders, the medical-style Bible of human psychological problems:

“Now, the DSM-IV was written by people , many of them psychologists, who have figured out every conceivable thing that can go wrong with us, which is very impressive. But I would like to suggest that it’s fundamentally, unintentionally, and insidiously violent to name someone by what’s wrong with them.”

I underlined that quote and thought I’d want to write something about it here. In class that week, it became clear that just about every other person in my cohort had underlined the same passage. We have all just taken a class on DSM diagnosis, because we will have to do it, out there in the world. Insurance companies won’t pay for problems that don’t have medical-sounding names. Major depressive disorder? Here, have some money. Isolated from any kind of supportive community, except for your mom, who you can’t stand for some reason? Hey, get a real problem, preferably one that we have a pill for.

Anyway, I think we all underlined that passage in part because it was so refreshing, after thinking so much about diagnostic categories. It’s also because that quote captures the spirit of the Couples and Family Therapy program we are in, and we were selected by our facultybecause quotes like that would resonate with us. It’s also because it’s so dang true. When you hear how many mental health professionals talk about their clients, it can be awful. ”I’ve got a Borderline at five o’clock,” as if what really matters about that human being is that their behavior fits the diagnostic criteria for Borderline Personality Disorder.

[First published on Nathen’s Miraculous Escape, April 30, 2010.]