Nathen

May 15, 2010

Rituals and Alcoholism in the Family

Posted by Nathen under alcohol abuse, children, family, family therapy, marriage and family therapy, parenting, psychology, rituals, Uncategorized
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I just read in Brock & Barnard’s Procedures in Marriage and Family Therapy about Wolin and colleagues’ research into rituals in alcoholic families. Apparently, the negative effects of an alcoholic parent were predicted better by the amount that family rituals were disrupted by the alcoholism than by the presence of alcoholism itself. For example, if the family continued to eat dinner together every night, continued with their bedtime rituals, etc, children remained about as well off as those in non-alcoholic households. But if the family rituals were destroyed, the children were much worse off, including much more likely to become alcoholic or marry an alcoholic themselves.

I haven’t read any of the original research, so I don’t know for sure if it is that these rituals actually provide resiliency or if the presence or lack of rituals served as a proxy measure for how bad the alcoholism was. It could also be a combination of the two. It does look like the family therapy literature considers that rituals promote resiliency in general, providing structure and comforting predictability for kids, and resulting in better outcomes. (I doubt they are bad for the adults, either.) Something to think about, parents!

May 14, 2010

Diagnostic Criteria for Oppositional Defiant Disorder

Posted by Nathen under adolescents, antidepressants, Attention-Deficit/Hyperactivity Disorder, children, diagnostic criteria, drugs, DSM-IV-TR, family assessment, family therapy, insurance companies, lists, mental disorders, obedience, Oppositional Defiant Disorder, practicum, psychopathology, psychotropic medication, SSRIs, stimulants
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According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), there is a mental disorder that is usually diagnosed in childhood or adolescence called Oppositional Defiant Disorder. It afflicts somewhere between 2-16% of people, more boys than girls before puberty, but equal numbers of boys and girls after puberty. Family therapists are not into giving medical-model diagnoses in general, but in many cases, a DSM diagnosis is the only way for a family to get their insurance companies to pay for them to get help. In one of my internship sites, for example, I will need to provide a DSM diagnosis after the first session with a family in order to get the clinic paid for our work. As I understand it, this is a common diagnosis for kids who are giving their parents and teachers a hard time.

Note that the word “often” is used to mean something like “more than usual,” so whichever kids who are most like this will qualify for this Disorder, as long as someone important believes that their behavior is significantly impairing their social or academic functioning. Note also that these symptoms could be occurring in just one setting (say, just at school) and the kid will still qualify for ODD, unlike the symptoms for ADHD, which have to occur in at least two settings to qualify for the diagnosis.

Outside of family therapy, ODD is very commonly treated with Ritalin for “comorbid” ADHD. Kids diagnosed with ODD are also fairly commonly given antidepressant and/or antipsychotic medication, on the guess that they have an underlying Mood Disorder or Bipolar Disorder, though there is little to no research on these medications for children, especially in combination.

The following is word-for-word from the DSM-IV-TR, page 102:

Diagnosis criteria for 313.81 Oppositional Defiant Disorder

A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

(1) often loses temper

(2) often argues with adults

(3) often actively defies or refuses to comply with adults’ requests or rules

(4) often deliberately annoys people

(5) often blames others for his or her mistakes or misbehavior

(6) is often touchy or easily annoyed by others

(7) is often angry or resentful

(8) is often spiteful or vindictive

Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

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

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 or older, criteria are not met for Antisocial Personality Disorder.

May 13, 2010

Parataxic Distortion

Posted by Nathen under co-counseling, countertransference, emotions, family therapy, going meta, Harry Stack Sullivan, parataxic distortion, psychology, Sigmund Freud, therapy, transference, words
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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 in your 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!

May 11, 2010

Divorce and Ideology?

Posted by Nathen under alcohol abuse, Americans, battering, Democrats, divorce, drug abuse, education, family values, headlines, marriage, National Public Radio, social class, statistics, unintended pregnancy
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I listened to a story on NPR a couple days ago about a how high divorce rates and teen-pregnancy rates are correlated to the state’s political ideology. Republican states have significantly more divorce and teen pregnancy. In fact, as a whole, the US divorce rate has been holding steady since the mid-90s, while the “red state” divorce rates (and teen-pregnancy rates) continue to rise. That means the blue states make up the difference and their rates are falling. NPR speculated that it’s because in family-values states, people get married earlier because of social pressure or so they can have sex, but choose badly because they don’t know themselves as well as they would several years later, when Democrats tend to get married. They also note that states that are swinging Democratic, like New Hampshire, are starting to have less divorce and teen pregnancy too.

It makes some sense, though I wouldn’t have guessed it. There are a couple of things not made explicit in the story that I wonder about. First, I wonder if the Republican fixation on “family values” issues is being driven by this phenomenon; to someone living in a Republican state, divorce and teen pregnancy are really pressing issues, because their ideology and behavior are not matching up. It could even be a vicious cycle: Values driving divorce driving values…. Second, I wonder how much of this has to do with money. Social class, really. Red states tend to be poorer, and poverty puts serious stress on a marriage. And poverty is correlated with a lot of other stressors, like substance abuse, domestic violence, and child abuse. Also, they mention that the demographic whose divorce rates are dropping the most are women who have graduated from college. I’ve been attending a state university for a few years now, and I can tell you that it’s not full of poor people. These kids (‘ parents) have money.

May 9, 2010

A Couple of Things About My Mama

Posted by Nathen under Darlene Lester, love, photography, writing
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My mother, Darlene Lester, is an amazing woman. I am lucky to be her son. Someday I will write a more eloquent post about that. Tonight I’ll just show you a couple things. First is a note that I wrote her when I was about four:

This note says a lot about my mom. First, she had taught me how to write letters by the age of four, which I think is unusual. I can still remember her teaching me to write “N.” (The secret, by the way, is to remember the phrase “Up, down, up.” That’s how she taught me.) The second is the story of the note. (This is as I recall you telling me, Mom–correct me if I’m wrong) I asked her to tell me what letter made each sound over quite a long period of time, maybe an hour or two, as I painstakingly sounded out my message. She was so available and patient with me! Third, the note says, translated, “I would like some orange juice. Signed Nathen.” I handed her the note when I was done with it, probably translating it for her, too. I was asking for orange juice, which was about the closest thing I ever had to candy until I was about nine years old. Mostly I was eating from my mom’s garden, goats, chickens, and the whole-foods co-op my mom helped run back in the 1970s in Joshua Tree. Fourth, my mom kept this note for thirty years. She gave it to me a few years ago and told me the story, still so delighted and proud that she had gotten to be with me, to spend so much time with me as a kid. My mom loves her sons so whole-heartedly! It’s been a pleasure and a privilege to be one of them.

Here’s a photo of us from about that time.

Nathen, Darlene, mid-1970s

Happy Mothers Day, Mom!

May 9, 2010

The Adverse Childhood Experiences Study

Posted by Nathen under alcohol abuse, battering, children, death, depression, disease, divorce, drug abuse, family assessment, lists, mental illness, neglect, parenting, physical abuse, predicting the future, rape, sexual assault, sexually transmitted disease, smoking, suicidality, unintended pregnancy
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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.

May 7, 2010

How Presently is Presently? (Or How Soon is Now?)

Posted by Nathen under English, Mandarin, rants, words, writing
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I don’t really have time to post. I’m busy reading sentences like, “There is ample clinical research methodology available presently, and such interactions can be reliably described, characterized, and codified in a relatively objective manner,” from page 412 of Textbook of Family and Couples Therapy, by Sholevar and Schwoeri.

There are several reasons that that sentence is an unpleasant read, but none of them are unusual in the books and articles I am reading. I think this kind of writing comes from a frustrated desire to have one’s field recognized as “real science.” Many important and useful ideas have been garbled by this desire.

What grabbed my attention here, though, was the use of the word “presently.” I read that and thought, can we really have a word that means both “soon” and “now”? Yes, we can, of course, but it’s a funny thing to do. When I was learning Mandarin by the Learnables method, where you just listen and look at pictures, I was unable to distinguish between the words for “on top of” and “underneath.” I made a big joke out of that. If you’re going to have a homonym in your language, don’t use it for two such closely related but different concepts! It would be like having the same word for up and down.

To a Mandarin speaker, though, the words for “on top of” and “underneath” sound quite different. “Presently” is even worse than a homonym for closely related but very different concepts. It’s the exact same word for them. Silly.

May 6, 2010

Not Back to School Camp: A Glance Within

Posted by Nathen under Allen Ellis, Blake Boles, blogging, Maya, Not Back to School Camp, photography, video
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Every year I work at a summer camp for home- and unschooled teenagers, Not Back to School Camp. This will be my twelfth year–thirty some sessions. It is usually the highlight of my year. An NBTSC alumni, Allen Ellis, made this video about it in 2009. Maya posted it on her blog a couple of months ago, and I’m copying her. In moments like this I really wonder who it is that reads my blog. I suspect you are 97% my family and NBTSC friends, who have already seen this. Oh well. This is for the other 3%, whose names are mostly David, Ceri, and Emily.

The guy in the still shot that heads the video is my friend Blake Boles. Every time I see this shot I wonder if Allen asked his permission to use it like that. It’s a funny one.

May 5, 2010

Assessing Sexual or Physical Abuse

Posted by Nathen under alcohol abuse, drug abuse, drugs, family assessment, family therapy, lists, parentification, physical abuse, practicum, sexual abuse, statistics, suicidality, violence
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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

May 4, 2010

Diagnostic Criteria for Conduct Disorder

Posted by Nathen under adolescents, children, Conduct Disorder, crime, cruelty, diagnostic criteria, DSM-IV-TR, lists, mental disorders, psychology, rape, sexual assault, violence
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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 and conduct 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

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