False Rape Allegations

Transcription

p.10
Demystifying
HIPAA
What Really
Provokes a False
Rape Charge?
Celebrating
False Allegations a New
Issue in Therapy
Understanding
Tai Chi
MENTAL HEALTH
PARITY!
Bill Finally Passed by Legislation
Why it is Helpful for Therapists
and Clients Alike
p.24
p.32
p.42
p.16
Issues of
Conversation
with a
College
Drinking
Genius: A Tribute to
Uncovered
Albert Ellis
A Study of Alcoholism and
its Effects in Young Adults
Pharmacology of
Autism Spectrum
Disorders
s
Linda Whitten Stalters
American Psychotherapy Association Liaison
Positive Change in the
Therapeutic Space
Coping Strategies
of African-American
Males: A Case Study
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Contents
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EDITORIAL ADVISORY BOARD
Alan Andrews, PsyD, DCSW, FAPA
Kelley Armbruster, MSW, LISW, DAPA
Alexander Baer, DMin, LPCC, DAPA
Harpriya (Sonya) A. Bhagar, MBBS
Maxine Moore Ballard, MS, DAPA
Dona Ragsdale Benz, MS, LPC, DAPA, CCFC, CISM
Linda Blinkman, MSW, DAPA
Patrick R. Bruns, DMin, FAPA
A. Crystal Busch, MSW, LCSW, DAPA
Sabrina Caballero, LCSW, DAPA
Ibrahim I. Chalhoub, PhD
Peter W. Choate, MSW, DAPA
James W. Clifton, PhD, LCSW, DAPA
Rona Sue Cohen, MA, CHES, CASAC, DAPA
John Cooke, PhD, LCDC, FAPA
Caryn Coons, MA, LPC, DAPA
Andre Sagrera Judice, PhD, LPC, LMFT
Walter C. Farrell Jr., PhD, MSPH, DAPA
Cathy Jo Faruque, PhD, LICSW, FAPA
John H. Flammer, EdD, PhD, CRS, DAPA
Sam Goldstein, PhD, DAPA
James L. Greenstone, EdD, JD, DABECI, FACFEI, DAPA
Richard A. Griffin, EdD, PhD, ThD, FAPA
June Groden, PhD, FAPA
Douglas Henning, PhD, FAPA
Noah Hart Jr., EdD, DAPA
Mark E. Hillman, PhD, FAPA
Debby L. Hirschhorn, PhD, LMHC, DAPA
Ronald Hixson, MBA, PhD, LPC, DAPA
Greg Johanson, MDiv, PhD, LPC, FAPA
Laura W. Kelley, PhD, DAPA
Gary Kesling, PhD, FAAMA, FAAETS
Michael W. Krumper, LCSW, FAPA
Ryan LaMothe, PhD, DAPA
Stephen Lankton, MSW, DAHB, DAPA
Allen Lebovits, PhD, FAPA
Frederick MacDonald, PhD, DAPA
Jeffrey D. McGrady, MDiv, MSW, CSW, DAPA
Sharon McLaughlin, LMFT, MA
Jeffrey J. Magnavita, PhD, DAPA
William Mosier, EdD, PA-C, DAPA
Natalie H. Newton, PhD, FAPA
Donald P. Owens Jr., PhD, DAPA
Larry H. Pastor, MD, FAPA
Richard Ponton, PhD, FAPA
Paul J. Schweinler, MDiv, MA, LMHC, NCC, DAPA
Daniel J. Reidenberg, PsyD, FAPA, CRS
Thomas Roberts, MS, LCSW, LMFT, DAPA
Irene F. Rosenberg-Javors, MEd, DAPA
Jeff Sandoz, PhD, LPC,
Maria Saxionis, LICSW, LADC-I, CCBT, CRFT, FAPA
Alan D. Schmetzer, MD, FAPA
Norman F. Shub, PhD, FAPA
William Martin Sloane, JD, LL.M, PhD, FAPA,
FAAIM, FACFEI
Shannon D. Smith, PhD, PCC, DAPA
Everett K. Spees, MD, PhD, DD, STD, DAPA
James Eugene Tille, DMin, PhD, LMFT, LMHC,
CDP, FAPA
Monty N. Weinstein, PsyD, MPA, NCP, FAPA
Stephanie Wise, MA, BCETS
Annals of the American Psychotherapy Association
Winter 2008 • vol. 11, no. 4
EXECUTIVE ADVISORY BOARD
features
10
2008 Term of Office
CHAIR: Daniel J. Reidenberg, PsyD,
FAPA, MTAPA, CRS
VICE CHAIR: Alan D. Schmetzer, MD,
FAPA, MTAPA
MEMBER EMERITUS: William Glasser, MD, MTAPA, FAPA; Bill O’Hanlon, MS,
FAPA, LMFT, MTAPA
By Willem Martens, MD, PhD
18
The Effects of College Tenure, Gender, and Social
Involvement on Alcohol Drinking and Alcoholism
in College Students
By Reuben Vaisman-Tzachor, PhD, FACFEI, DAPA, CHS-III, and
Judy Y. Lai, PhD, MFT
BOARD MEMBERS
John Catlett Jr., MEd, BCPC
Peter W. Choate, MSW, DAPA, MTAPA
Fay Hart, FAPA, BCPC, ACMC-III, MTAPA
Noah Hart Jr., EdD, DAPA
Ron Hixson, PhD, MBA, LPC, LMFT, DAPA,
MTAPA, BCPC
Luniece E. Obst, MEd, LPC, BCPC
David E. Rosengard, RPh, MD, MPH,
PhD, FAPA, FACA, MTAPA
Wayne E. Tasker, PsyD, DAPA, BCPC
Karl P. Ullrich, PhD, FAPA, MTAPA
26
Rx Primer: Fibromyalgia and Antidepressants
30
Understanding Tai Chi: An Interview with Michael
Gilman
35
Expert Panel: Substance Abuse in Adolescents
By Harpriya A. (Sonya) Bhagar, MBBS
Moderated by Marino Carbonell, EdD, Life Fellow
40
Founder and Publisher: Robert L.
O’Block, MDiv, PhD, PsyD, DMin
(rloblock@aol.com)
Introjective Identification Therapy for Patients
with Antisocial Personality Disorders
Celebrating Mental Health Parity
columns & case studies
Editor in Chief: Amber Ennis
(editor@americanpsychotherapy.com)
Associate Editor: John Lechliter
(john@americanpsychotherapy.com)
Assistant Editor: Logan Forester
(logan@americanpsychotherapy.com)
Executive Art Director: Brandon Alms
(brandon@acfei.com)
27
Culture Notes: The Work of Psychotherapy
45
Issues in Therapy: False Rape Allegations
50
Chair’s Corner: Reflections on the Annual
Conference
By Irene Rosenberg-Javors, MEd, LMHC, DAPA
By Bruce Gross, PhD, JD, MBA, FACFEI, DABPS, DABFE,
DABFM, FAPA
By Daniel J. Reidenberg, PsyD, FAPA, CMT, CRS, MTAPA
Chief Association Officer: Aaron Nesbitt
(aaron@americanpsychotherapy.com)
52
Photography: www.istockphoto.com
Practice Management: Sticks and Stones and Other
Tales
By Ronald Hixson, PhD, BCPC, MBA, LPC, LMFT, DAPA
Annals of the American Psychotherapy Association (ISSN 1535-4075) is published quarterly by
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Mind News
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Book Reviews
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MIND NEWS
Chaplains Play Vital Role in Psychotherapy
A military chaplain may not be the first thing
that comes to mind when most think of psychotherapy. Nevertheless, these mental and
spiritual health providers are working day in
and day out in an attempt to talk out life’s
frustrations with their clients—in this case,
the clients are military personnel.
Henry Beaulieu, a Montgomery, Alabama,
pastor and chaplain, spent a year in Baghdad with a National Guard unit. In
an article in the Montgomery Advertiser, he tells of the stories and the soldiers
he met with who were struggling with their experiences of trauma and loss.
Similar to everyday civilians, some handle these experiences well, and others
react in ways that interfere with their ability to perform daily tasks and live
normal lives.
MCT Illustration by Rob Hernandez/San Jose Mercury News
“Sometimes you have somebody bang on your door at 2 in the morning
because his buddy is back in the dorm having a recurring nightmare because
one of his buddies got killed or blown up,” Beaulieu said.
Military chaplains are present at all times with the troops, participating in
fitness training and other skills to prepare them for deployment. The chaplains
accompany the soldiers to provide spiritual care not only with combat-related
trauma, but also the stress of relationships, loneliness, and boredom.
For more information on the role of chaplains or to learn more about APA’s
Academy Certified Chaplain program, please visit www.americanpsychotherapy.com.
Rowell, J. (2008, October 13). Chaplains use ‘ministry of presence.’ Montgomery Advertiser. Retrieved October 14, 2008, from http://www.montgomeryadvertiser.com/apps/pbcs.dll/article?AID=/20081013/NEWS01/810130304
Dating Violence in Men Linked to Troubled Early Years
The study—conducted by Elizabeth Miller,
an assistant professor of pediatrics at UCDavis Children’s Hospital, and Elizabeth
Reed, a graduate student at Harvard at the
time of the study—attempts to shed light on
the lives of teenage boys who abuse their girlfriends. Although there are multiple studies
on the consequences of dating violence for
girls, Miller claims that this is the first study that focuses on understanding
the fundamental social and environmental factors that promote male violence: information that is crucial to prevent it.
Miller stated that the solution is “to look beyond individuals to see how
environments play a role … and address the issue in a way that considers factors much larger than individual choices and behaviors.” The study is from
MCT Illustration by Rob Hernandez/San Jose Mercury News
an urban sample of boys in programs for dating violence; therefore it does
not represent all boys who perpetrate abuse toward their significant others.
However, it might offer initial insights into the environmental factors of boys
that may contribute to violence, such as problematic home environments,
inadequate support at school, communities characterized by violence, or peer
interactions that encourage the sexual mistreatment of girls.
Miller is also conducting a research study on dating violence prevention
called Coaching Boys into Men, sponsored by the Family Violence Prevention
Fund, which trains coaches to work with at-risk, high-school-aged athletes
to stop violence towards girls.
University of California-Davis Health System. (2008, October 17). Study looks at
the lives of boys who commit dating violence. ScienceDaily. Retrieved October 20,
2008, from http://www.sciencedaily.com/releases/2008/10/081014204448.htm
Spending Time With Nature Reduces ADHD Symptoms, Study Shows
A recent study suggests that those children suffering from Attention Deficit Hyperactivity
Disorder (ADHD) may benefit from simply taking a walk through a nature-filled environment.
“From our previous research, we knew there
might be a link between spending time in nature and reduced ADHD symptoms,” said
Andrea Faber Taylor, a researcher with the University of Illinois study team.
After taking children on a walk through a “green” environment and then
through residential settings and downtown areas, the researchers found that
the children exhibited better concentration and improved attention spans
upon returning from the “green” walk. There is no speculation on what exactly causes the improved concentration, but a measurable difference was
observed in the participants’ symptoms.
MCT Illustration by Erick Marquez/The Kansas City Star
“What this particular study tells us is that the physical environment matters,” said Faber Taylor.
She thinks the results of this study will be extremely helpful to parents of
ADHD children. By simply taking their children out for a walk in the park,
they can test for themselves whether symptoms improve. Additionally, Faber
Taylor thinks calming physical environments can benefit children and adults
alike, whether or not they suffer from ADHD.
The results of the study can be found in the Journal of Attention
Disorders.
Nauert, R. (2008, October 17). Walk in the park may help kids with ADHD.
PsychCentral. Retrieved October 20, 2008, from http://psychcentral.com/
news/2008/10/17/walk-in-the-park-may-help-kids-with-adhd/3152.html
Therapy Over the Phone More Effective Than In-Person Sessions?
Nearly all psychotherapists will agree that
therapy sessions are effective at eliciting a desired result from a client. However, if clients
fail to keep up attendance at the sessions, the
therapy cannot work.
In a study performed by researchers at
Northwestern University’s Feinberg School
of Medicine, results showed that therapy performed over the phone for clients suffering from depression yielded results similar to those in in-person treatment. Additionally, only 7.6% of patients quit the
phone therapy, as opposed to the nearly 50% who quit in-person treatment.
Lead author of the study, David Mohr, said, “One of the symptoms of depression is people lose motivation ... It’s hard for them to do the things they
are supposed to do. Showing up for appointments is one of those things.”
Therapy performed over the telephone allows for fewer emotional barriers
between the patient and therapist. Many patients may find it easier to communicate feelings over the phone. Busy schedules also push telephone therapy to be a more comfortable fit for those who do not seem to have enough
hours in the day to make it to the therapist’s office.
Mohr expects additional studies in the future to shed even more light on
the efficacy of telephone therapy.
Northwestern University. (2008, September 22). Patients stay with phone psychotherapy longer than office visits. Retrieved October 20, 2008, from http://
www.brightsurf.com/news/headlines/40360/Patients_stay_with_phone_psychotherapy_longer_than_office_visits.html
Effective Treatment for Depression: St. John’s Wort
All who have known someone suffering from
depression are aware of the toll the disease
and the medication can take on the victim.
Now those living with symptoms of depression may find relief through taking St. John’s
wort.
German researchers performed 29 total
trials on 5,489 individuals presenting with
symptoms of depression. Using the Hamilton Rating Scale for Depression,
participants were asked to rate the severity of their depression after taking
various treatments. Results showed that the extract was as effective as other
antidepressants, and it also had fewer side effects.
While the study results are promising, the big picture is somewhat more
difficult to assess due to “the fact that the results were more favourable in tri-
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MCT Illustration by Kathy Hagedorn/Akron Beacon Journal
als conducted in German speaking countries, where St. John’s extracts have
a long tradition and are often prescribed by doctors.”
The study, however, is a step in the right direction. Though, consumers
should be warned that purchasing just any generic type of St. John’s wort
may not be the answer.
Klaus Linde, lead researcher from the Centre for Complementary Medicine
in Munich, Germany, stated, “Using a St. John’s wort extract might be justified, but products on the market vary considerably, so these results only apply to the preparations tested.”
Wiley-Blackwell. (2008, October 13). St. John’s Wort relieves symptoms of
major depression, study shows. ScienceDaily. Retrieved October 20, 2008,
from http://www.sciencedaily.com/releases/2008/10/081007192435.htm
Surfing the Web May Improve Brain Health in Older Adults
Performing an Internet search is a daily task
for many Americans. Most search the Web
looking for answers to questions, however big
or small. Now scientists at the University of
California, Los Angeles, are suggesting that
older adults who perform this task may be
improving brain function as well.
The UCLA study involved 24 adults between the ages of 55 and 76, half of which had previous experience with surfing the Internet. As the participants performed the Web searches, the researchers monitored their cerebral blood flow through the use of MRIs. Results of
the study showed that certain centers in the brain responsible for decision
making and reasoning were triggered, but only in the group who were familiar with the Web. Those who had no previous experience did not exhibit the
MCT Illustration by Kirk Little/Saint Paul Pioneer Press
MCT Illustration by Tim Lee/The News & Observer (Raleigh, N.C.)
same levels of brain activity, perhaps due to the experience being brand new.
Dr. Gary Small, Director of UCLA’s Memory and Aging Research Center,
proposed that perhaps with more online exposure, the beginning group of
Internet searchers could reach the same level of brain activity as the more experienced group.
“The study results are encouraging that emerging computerized technologies may have physiological effects and potential benefits for middle-aged and
older adults,” said Dr. Small.
The complete findings from the study will be published in an upcoming
issue of the American Journal of Geriatric Psychiatry.
Parker-Pope, T. (2008, October 16). Surfing the Internet boosts aging brains.
New York Times. Retrieved October 20, 2008, from http://well.blogs.nytimes.
com/2008/10/16/does-the-internet-boost-your-brainpower
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CE ARTICLE 1: INTROJECTIVE IDENTIFICATION THERAPY (pages 10-16)
ATTENTION APA MEMBERS: CEs are now FREE when taken online. Visit www.americanpsychotherapy.com.
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CE ACCREDITATIONS FOR THIS ARTICLE
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This article is approved by the following for continuing education credit:
1. Read the continuing education article.
2. Complete the exam by circling the chosen answer for each question. Complete the evaluation form.
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APA, 2750 East Sunshine, Springfield, MO 65804. Or Fax to: (417) 823-9959. Or go online to
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LEARNING OBJECTIVES
After studying this article, participants should be better able to do the following:
1. Name three ways in which introjective identification can be used in treatment of antisocial
personalities.
2. List three ways in which the therapist can include or integrate elements of Introjective
Identification Therapy in other therapeutic approaches.
3. Name at least two previously established treatments of ASPD and explain their efficacy.
KEY WORDS: antisocial personality disorder, introjective identification therapy
TARGET AUDIENCE: mental health professionals, therapists, psychologists, counselors, social workers
PROGRAM LEVEL: Basic
DISCLOSURE: The author has nothing to disclose.
PREREQUISITES: none
ABSTRACT
Treatment of persons with Antisocial Personality Disorder (ASPD) (American Psychiatric Association, 2000) is often challenging despite all the new treatment approaches, such as specific therapeutic
programs for distinctive target populations and new developments in existing therapeutic traditions (Kahn, Oppenheimer, & Martens, 2007; Martens, 2001a, 2001b, 2002, 2003). The deep-rooted
deviant behavioral and personality characteristics of those with ASPD are in severe cases very difficult to transform to less harmful and more socially desirable features and attitudes. I was inspired by
two case studies of individuals with ASPD, illustrating the healing effects of positive identification (which will be presented later), and by the film Love and Death on Long Island, in which an author
is intrigued by a young B-movie actor demonstrating a light and popular lifestyle and behavior complementary to that of the author’s own. Because of this inspiration, I developed new theoretical
building blocks for Introjective Identification Therapy (IIT), designed for antisocial personalities.
POST CE TEST QUESTIONS
(Answer the following questions after reading the article, pages 10-16)
1. Which of the current treatment approaches are most effective for persons with
Antisocial Personality Disorder?
a) cognitive behavior therapy
b) psychodynamic therapy
c) therapeutic community treatment
d) combination of psychopharmacological, neurofeedback, psychotherapeutic treatment, and psychosocial guidance
2.True or false: Lacan introduced the significant concept of self that relies on one’s
(mis-) identification with the image of another.
a) True
b) False
3.True or false: According to Kernberg’s theories of introjection, images are so
important because it is necessary to realize the interaction with the outside
world.
a) True
b) False
4.Introjective Identification Therapy is a therapeutic approach that is mainly
focused on systematic and strategic:
a) increase of socially desirable character
b) decrease of criminal tendencies
c) increase of capacities of social interaction
5. Psychotic and traumatic patients should be excluded from IIT because lack of
reality testing and lack of tranquility will lead to:
a) lack of therapeutic motivation
b) self-destructive intentions
c) complication and interference with therapeutic process
6.True or false: Therapeutic correction of language use and exact grammatical formulation in the therapeutic process of IIT especially is immportant because these
careful linguistic activities should provide an exact line-up and structure for mental and emotional forces/activities that are required for introjective identification
and the transformation process.
a) True
b) False
EVALUATION: Circle one (1=Poor 2=Below Average 3=Average 4=Above Average 5=Excellent)
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800-205-9165.
Name:
1. Information was relevant and applicable.
2. Learning objective 1 was met.
5. You were satisfied with the article.
6. ADA instructions were adequate.
7. The author’s knowledge, expertise, and clarity were appropriate.
8. Article was fair, balanced, and free of commercial bias.
9. The article was appropriate to your education, experience, and
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10. Instructional materials were useful.
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CE Article: 1 CE credit for this article
Introjective Identification Therapy
for Patients With Antisocial
Personality Disorders:
A Theoretical Outline
By Willem Martens, PhD, MD
reatment of persons with Antisocial Personality Disorder
(ASPD) (American Psychiatric Association, 2000) is often challenging despite all the new treatment approaches, such as specific therapeutic programs for distinctive
target populations and new developments in existing therapeutic traditions (Kahn, Oppenheimer, &
Martens, 2007; Martens, 2001a, 2001b, 2002, 2003).
The deep-rooted deviant behavioral and personality characteristics of those
with ASPD are, in severe cases, very difficult to transform to less harmful and more socially desirable features and attitudes. I was inspired by
two case studies of individuals with ASPD, illustrating the healing effects
of positive identification (which will be presented later), and by the film
Love and Death on Long Island, in which an author is intrigued by a young
B-movie actor demonstrating a light and popular lifestyle and behavior
complementary to that of the author’s own. Because of this inspiration, I
developed new theoretical building blocks for Introjective Identification
Therapy (IIT), designed for antisocial personalities.
Definition of ASPD
The 4th edition of the Diagnostic and Statistical
Manual of Mental Disorder (DSM-IV TR), presents features of Antisocial Personality Disorder
(ASPD):
• A failure to conform to norms with respect
to lawful behaviors as indicated by repeatedly
performing acts that are grounds for arrest
• A deceitfulness, as indicated by repeated lying,
use of aliases, or conning others for personal
profit or pleasure
• An impulsivity or failure to plan ahead
• An irritability and aggressiveness, as indicated
by repeated physical fights or assaults
• A reckless disregard for the safety of self or others
• A consistent irresponsibility, as indicated by
repeated failure to sustain consistent work behavior or to honor financial obligations
• A lack of remorse, as indicated by being indifferent to or rationalizing having
hurt, mistreated, or stolen from another
Additionally, the individual must be at least 18
years of age, although there is evidence of DSMIV Conduct Disorder before he or she is 15 years
old. Antisocial behavior does not occur exclusively during the course of a schizophrenic or manic
episode.
Established Methods of Treatment
of ASPD and Success Rates
Studies into the treatment efficacy in adult psychopaths offer these findings:
• There is mixed evidence that therapeutic communities (TC) are effective in ASPD (Kahn
et al., 2007; Martens, 2004b). Treatment of
ASPD in therapeutic communities is problematic in terms of high rates of attrition, low levels of motivation, and increased reconviction
(Kernberg, 1984, 1992; Martens, 1997), but
in some cases it might be successful. The author suggests that differences in the a) personal
schemes of treatment, b) treatment diversity, c)
presence or absence of experimental attitudes
of staff members, d) management, e) selection, and f ) availability of high qualified and
motivated therapists and staff members might
be (partly) responsible for distinctions in treatment outcome between various studies.
• Psychotherapeutic (especially cognitive, behavioral, and psychodynamic psychotherapy)
treatment could be effective in the long run
(generally meaning at least 5 years of treatment) in some cases (depending on study populations, 5%–25% remission, and 10%–30%
improvement rates), in so far that ASPD
personality traits become less extreme (Kahn
et al., 2007; Martens, 2004b). Psychoanalytiwww.americanpsychotherapy.com
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“...THERAPEUTIC
OBSERVATION AND
CORRECTION OF
LANGUAGE USE MIGHT
PLAY A SIGNIFICANT
ROLE IN INTROJECTIVE
IDENTIFICATION
THERAPY.”
cal treatment might be effective, but no remission and improvement rates are available
(Kernberg, 1984, 1992; Martens, 1997,
1999). Nevertheless, even those in remission
seldom reject their egocentric attitudes; thus
they continue to have interpersonal problems.
Here again, differences in treatment-outcome
studies may be explained by distinctions in
personal schemes of treatment and the availability of highly qualified and motivated therapists, management, and selection.
• Short-term behavioral therapy and group psychotherapy do not seem to be effective in treating ASPD (Kahn et al., 2007; Martens, 2004).
• Because many antisocial traits such as aggression, impulsivity, sensation seeking,
incapacity to learn from experiences, and
lack of social-emotional and moral capacities are neurobiologically determined (Martens, 2005b), it may be possible to diminish
these traits with the help of psychopharmacological treatment (Martens, 2002), neurofeedback treatment (Martens, 2002),
and psychosocial guidance in combination
with psychotherapy (Martens, 1997, 2002).
Definition of Projection, Introjection,
and Introjective Identification
Projection is the initial phase of introjection—its
condition of possibility. Projection can be defined
as the perceptual process that tests and evaluates
the object in terms of acceptability to self. It is the
insertion of self into the object by the subject with
the immediate and mostly unconscious purpose of
assessing the object either as nourishing or toxic
(Malancharuvil, 2004).
Kernberg (1976) provided a definition:
“[Introjection] is the reproduction and ﬁxation of
an interaction with the environment by means of
an organized cluster of memory traces implying at
least three components: (a) the image of an object,
(b) the image of the self in interaction with the object, and (c) the affective coloring of both the object-image and the self-image.”
Selection of Patients for Introjective Identification Theory
Adequate motivation; a minimum of intelligence
and cognitive abilities; sufficient character
strength and flexibility (is necessary to include
representations of the idealized persons in his/
her own character without losing his/her own
authentic core cohesion; capability to (or able to
learn how) cooperate with the therapist; patient
must demonstrate deviant characteristic that
could be improved by IIT (for instance, persons
who developed a personality disorder as a
consequence of aversive environmental and
psychosocial influences of parents, peers, and
neighborhood).
Severe traumatic experiences that are linked
to antisocial personality disorder (see Martens,
2005a) and patients with co-morbid psychotic
disorders and bipolar disorders should be
excluded from Introjective Identification Therapy
because these patients demonstrate a lack of
reality testing (psychotic and bipolar patients)
and lack of internal/external tranquility, too much
confusion that might complicate or interfere with
Introjective Identification Therapy.
Introjective Identification (II) occurs when there
is a process of introjection (inclusion, incorporation)
and when an identification with what is introjected
is added to this. Different writers, particularly those
of the Kleinian school (Klein, 1950; Segal, 1964),
refer to the introjection of the object into the ego
and to the subsequent identification of the ego with
this object, when they discuss introjective identification. Adroer (1998) suggests, however, that II can
also occur in the self, although it is outside the ego
(in pathological states).
Lacan’s View On Imaginary Identification
and Significance Of Language
Lacan’s conclusions are based on psychodynamic observations and research. In his essay on the
Mirror Stage, Lacan (1977) describes how the infant forms an illusion of an ego, of a unified, conscious self, identified by the word I. To Lacan, ego
(self, or Identity) is always on some level a fantasy,
an identification with an external image, and not an
internal sense of a separate whole identity. Rather,
self is other, in Lacan’s view; the idea of the self, that
inner being we designate by I, is based on an image,
an other. The concept of self relies on one’s (mis-)
identification with this image of an other (Lacan,
1963, 1977, 1981).
Central to the conception of the human, in Lacan,
is the notion that the unconscious, which governs
all factors of human existence, is structured like a
language. He bases this on Freud’s account of the
two main mechanisms of unconscious processes:
condensation and displacement. Both are essentially linguistic phenomena, where meaning is either
condensed (in metaphor) or displaced (in metonymy) (Lacan, 1963, 1977, 1981). The elements in
the unconscious—wishes, desires, and images—all
form signifiers usually expressed in verbal terms, and
these signifiers form a signifying chain—one signifier
has meaning only because it is not some other signifier. Lacan, on the other hand, says that the process
of becoming an adult, a self, is the process of trying
to fix, to stabilize, or to stop the chain of signifiers
so that stable meaning—including the meaning of
I—becomes possible (Lacan, 1963, 1977, 1981). As
a consequence, therapeutic observation and correction of language use might play a significant role in
introjective identification therapy.
What is Introjective
Identification Therapy?
Introjective Identification Therapy is intended
to be an adjunct to current therapeutic strategies
rather than a substitute. Introjective Identification
Therapy is a therapeutic approach mainly focused
on systematic and strategic increase of socially desirable character traits, attitudes, or behaviors of
patients with ASPD by means of positive identification with a person or image. It could be a real or
fictional character from movies, books, politics, religion, culture, etc. who demonstrates
features that are considered ideal for achievement (this will be referred to as an idealized
person) by the patient, and are complementary and a valuable addition to the features
of the patient. Subsequently, the patient
would learn to let flourish and maturate
the new revealed parts of his or her self (by
means of conscious utilization and training
of these abilities and characteristics) in such
way that it becomes a substantial and active
dimension. The ideal transformation process
can be considered a discovery of the hidden
sources and components of self, rather than
the “blind” inclusion of characteristics of a
stranger. The correction of self-concept, increase of self-knowledge and self-esteem/respect, growth of social-emotional and moral
capacities, spiritual activities, gradual increase
of responsibilities, and training of pro-social
coping skills might be significant additional
issues in this approach (and/or other therapeutic approaches that could be combined
with IIT), because these are significant correlates of improvement and remission in persons with ASPD (Black, Baumgard, & Bell,
1997; Martens, 1997; Robins, 1966).
Preparation of Patients
Therapists should prepare motivated patients
for this new therapeutic approach by teaching them the following:
• the correct and adequate utilization of
identification (using test cases, for example)
• effective patient-therapist cooperation
and adequate responses to therapeutic
guidance during identification activities
• replacement/empathic skills
• pro-social coping strategies so patients
can handle difficulties that arise as a
consequence of their attitude change
(acceptance problems with their environment, peers, friends, and partner)
The therapist should inform the patient
adequately and completely (discussion of
risks, possibilities, and rules) in order to
create realistic expectations and an efficient
therapeutic attitude.
Therapeutic Steps and Strategy
Recognition of undesirable traits. By means
of intensive and careful self-investigation, the
patient should select his or her traits and attitudes that are undesirable and should be rejected. It might be useful to evaluate past efforts to change attitude or behavior (and to
diminish these undesirable features). What
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can the patient learn from these attempts?
The second step in the therapeutic process is
to find an appropriate idealized person (some
individuals cherish several) who demonstrates
characteristics that might be suitable for addition to the traits or attitudes of the patient and
as a substitute for the rejected features.
Idealized person. Patients must learn to collect information regarding the idealized person, and they must do some homework in
order to become motivated in a realistic and
effective way. They should be stimulated to
discuss their observations and visions with
respect of the idealized person in a profound
and nuanced manner with their therapist.
However, the therapist must be very alert to
a patient’s attraction to harmful features of
the idealized object, and the therapist should
discuss these harmful influences with the
patient in a very early stage. It should also
be discussed why the idealized person is a
special person and which features could be
regarded as ideal for the patient. Therapists
and patients should also discuss whether successful identification is a realistic goal. Only
realistic goal setting and a realistic concept
of examples are useful and harmless. When
these matters are investigated and the results are positive, the main therapeutic process can begin.
The patient must learn to discover, in a systematic and profound manner, the internal
(emotions, ideas, drives, and attitude) and
external (expectations and reactions from the
outside world) life of the idealized person.
Pro-social role models, ideas, emotions, and
behaviors/attitudes of other persons play a
major role in the transformation process because successful social-emotional and cognitive interactions with the external world might
have a corrective (utilization of relevant feedback from other people), refreshing (bringing new views and perspectives into our life),
and creative influence (increased self-investigation and examination of alternative possibilities for attitude and behavior, discovering
our own hidden talents and capacities). But,
in Introjective Identification Therapy, it is a
necessity to optimize and watch this process
of receiving influences carefully and continuously in order to avoid harmful influences and
to intervene when avoidance is not possible.
Harmful influences are possible as a result of
over-idealization and wrong interpretation of
the traits and attitudes of the idealized person by the patient. The therapist must also be
watchful for the impact of undesirable traits
(that should be excluded from the therapeutic
process) on the patient by means of intensive
therapeutic process control (assessment and
continual monitoring of vulnerable points in
the therapeutic process and attitude of the patient).
Imitation and creative play. Thoughtful social information processing and social comparison activities (what are the differences
between and similarities of the idealized person and other persons) in combination with
empathic and cognitive investigation in the
external and internal world of the idealized
individual must lead to an establishment of
a stable and realistic internal representation
of the idealized figure. Intense connectedness
and interactions with this representation of
the idealized figure is required to borrow his
or her desired characteristics and attitude (by
means of observation, comparison, self-perception/reflection, and imitation).
In fact, students of old masters such as
Rembrandt and Bach learned first to copy
(imitate) the work of their teacher in order
to observe the precise technique of art and
find out how it works. After that, the student
might be better able to develop his or her
own style. By means of imitation, the patient
might discover the rudimentary parts of him
or herself that correspond with the desired
features and/or attitude of the idealized person.
The patient can wake up these rudimentary capacities in his or herself and let them
grow and maturate so that they become a
substantial and active part of his or her self.
The characteristics of the idealized person
that were studied and imitated might be
gradually adapted (when therapeutic guidance is adequate) and transformed from incorporated parts (representations of the idealized person) into the patient’s authentic
structure and the “substance” of the patient’s
character and core of self.
The therapist must stimulate the patient’s
ability to creative imitation (play with the internal representations of the idealized person
and adopt it in a genuine way), while blind
imitation should be discouraged. Our intrapsychic world is able to use creatively prepared
external influences (also as a consequence of
imitation, social comparison, impressive external information and events, social support,
and positive attention) to create a new intrapsychic balance, specific self-recovering activities, and a change of character or attitude
(this happens even in patients with antisocial
and psychopathic personality disorders; see
Martens, 1997). I agree with Adroer (1998)
and Grotstein (1983), who suggested that, “what
one internalized is not so much the object and its
functions, as one’s experience with the object.”
Language. The therapist and patients should watch
language use during the motivation phase (patients’
expression of desires, needs, and goals), during the
selection of the idealized subject for introjective identification, and during the process of IIT itself, because
it will contain significant unconscious information.
Furthermore, emphasis on therapeutic correction of
language use and exact grammatical formulation in
the therapeutic process is important because these
careful linguistic activities should provide an exact
line-up and structure (framework) for mental and
emotional forces or activities that are required for
introjective identification and the transformation
process (for more details see Lacan, 1981).
Coping with relapse or crisis. Finally, the patient and therapist should evaluate the transformation process to provide useful information for
coping with relapse or crisis in the future. The
patients must find out what the learning moments
and conditions are that correlate with positive experiences in finding solutions for problems and
how he or she can use this information adequately for prevention or intervention with problems
in the future.
Aspects of Therapist-Patient Relationship
In therapy, the therapist becomes a new object in
the client’s life, thus activating the dynamic of transference (Van Beekum, 2005). I agree with Scharff ’s
(1992) view that the power of therapeutic action
derives from the mental mechanisms of projective
and introjective identification (Scharff, 1992). This
is especially the case in Introjective Identification
Therapy. Eshel’s (2004) experiences and observations indicate that the crucial step at the heart of the
process, between projective identification at its onset
and the patient’s introjective identification later on,
is the analyst’s experience of being-in-identification
with the patient’s projected, threatening, and painful experiences.
The analyst actually lets the patient’s experiences in
and processes them within his or her own emotional
experience. This is referred to as I-dentification (see
Lacan), experiencing vicarious experience and the ensuing possibility of being. Containing thus evolves
through the patient and analyst’s converging, deep
interconnectedness and interpenetrating impact on
each other, forming a conjoint, living, therapeutic
entity in which the analyst’s psyche is used as an area
of experiencing and transformation for the patient’s
expelled, unbearable experiences (Eshel, 2004). The
author also suggests that the identificatory, an indepth understanding of the patient, is achieved by
the analyst’s staying as connected as possible to the
patient’s emotional experience.
The therapist’s self is the therapeutic instrument, and the therapist must provide a holding
environment: a therapeutic space free of impulsivity, narcissistic concerns, and retaliation (Scharff,
1992). Scharff ’s technique of listening to the unconscious communication coming from the patient
in words, silence, gestures, and in feelings evoked in
us is suitable for Introjective Identification Therapy.
Furthermore, the therapist must follow the affect,
analyze dreams and fantasies, and point out the
compulsive repetition of unhealthy behavior due
to unresolved conflict.
These therapeutic issues of the therapist-patient
relationship require attention:
• Therapeutic increase of faith (antisocial personalities have problems with trusting others).
Many current therapeutic approaches include
strategies for stimulation of the patient’s faith
in the therapist.
• Enhancement of reliability in therapeutic relationships (deception and unreliability are
diagnostic features of Antisocial Personality
Disorder) by means of clear agreement and
strict rules (that include consequences of unreliable behavior).
• Decrease of antisocial characteristics such as
impulsivity, recklessness, and sensation seeking (which are frequently neurobiological determined, see Martens, 2005b) by means of
adequate multidisciplinary treatment (combination of psychotherapeutic, neurological
treatment, and psychosocial guidance, see
Martens, 2002).
• Influences of frequent co-morbid disorders
in antisocial persons such as substance abuse
disorders and other personality disorders must
be considered.
• Therapeutic use of humor might have a positive and healing effect on the therapist-patient
relationship and therapeutic process (see Martens, 2004a).
Case Report 1
Mr. X had murdered his wife and several of her lovers
in a very brutal way during an outburst of extreme jealousy and related rage. He was sentenced to a forensic
psychiatric treatment, because he was found not guilty
by reason of insanity. He was diagnosed according to
the DSM-II (American Psychiatric Association, 1968)
as suffering from Antisocial Personality Disorder. He
demonstrated severe impulsive, aggressive, reckless,
and callous traits, serious social-emotional and moral incapacities, and a long-lasting alcohol problem.
He was frequently in trouble with the law as a consequence of fights and reckless driving. Mr. X was 33
years old and of average intelligence. He liked social
contacts but in a less subtle, empathic, and a rather
indifferent way. At many times he demonstrated unpredictable and aggressive behaviors.
Mr. X grew up in a poor neighborhood.
Both his parents had criminal and antisocial
traits and had heavily abused alcohol. They
had six children who were often neglected.
Mr. X finished technical school and worked
for 12 years as a car mechanic. He was only
interested in boxing and car racing. He became a member of a street gang when he was
13 years old and, under the influence of other gang members, he began participating in
criminal activities such as burglary, robbery,
and physical assaults; however, he was only
arrested for fights.
In the forensic hospital, he was confronted
on his ward by patients with different backgrounds (milieu, education, attitudes, and interests). It was remarkable that he became a
close friend of Mr. Y, who was a hippie. The
court sentenced Mr. Y to forced treatment because he had killed his wife before attempting
suicide, hoping to die with her. Mr. X was intrigued by Mr. Y because of his stories (he traveled around the world) and his wisdom (he had
read many books of Herman Hesse, Buddha,
and so on). These two men spent much time
together. Mr. X was very much impressed by
and under the influence of Mr. Y’s attitude.
He was relaxed and cultivated; he coped with
problems by means of subtle and constructive humor, and he was a good thinker. Mr. X
changed his behavior and attitude gradually.
His brutal and rough behavior diminished,
and he made serious attempts to behave (control his irritating, impulsive, and aggressive
impulses) and think in a civilized manner. He
practiced gentle behavior because he observed
the positive effects of Mr. Y’s behavior (everybody liked Mr. Y and gave him positive attention) and experienced satisfaction as a consequence of his new attitude. In the beginning
he avoided stressful and aggression-provoking
situations. Gradually, he tried (sometimes with
help of Mr. Y) to cope with stressful and frustrating situations in a socially desirable manner. For example, he tried more and more to
express his irritation and aggression precisely
and structured in words and adequate emotions, rather than in an explosive way.
After a year of friendship, Mr. Y committed suicide. Mr. X became very depressed as a
consequence of the death of his friend. It was
remarkable that he was able to use Mr. Y’s
example in an adequate and structural way
after Mr. Y’s death. Mr. X’s psychotherapist
encouraged him to optimally use the positive
impact of Mr. Y’s features and attitude and to
also work it out in psychotherapeutic sessions.
Mr. Y was the mirror in which Mr. X saw his
own limitation. In this way he became moti(800) 592-1125
vated to lastingly change his behavior and attitude, while he borrowed and experimented
with the characteristics of Mr. Y. Aggressive
impulses were transformed in a creative basis
that was required for stable, gentle behavior.
When he was irritated or provoked by a fellow patient, he realized more and more that
subtle reactions were much more effective and
satisfying than brutal ones. Furthermore, this
new attitude also increased his self-esteem and
cognitive and social-emotional capacities.
Mr. X found the support of the psychotherapist a great help in his battle to become
a more desirable person, and after 3 years of
intense psychodynamic psychotherapy he was
ready to finish forensic psychiatric treatment.
He demonstrated an impressive growth of
self-knowledge, social-emotional, and moral
capacities, and he discovered the soft, subtle,
and mild side of himself. Mr. X has been free
for 24 years and has never re-offended. He has
been happily married for many years.
Case Report 2
Mr. A was sentenced to prison because of
criminally fraudulent activities such as deceitful bank transactions and forgery. He suffered
from DSM-III Antisocial Personality Disorder,
neurobiological determined impulsivity, and
social-emotional incapacities, which might be
related to long-lasting aversive experiences and
injuries (head injuries and emotional trauma)
as a soldier in battle situations during World
War II in Korea and Algeria. As a veteran, he
was unable to adjust socially, adhere to a normal daily routine (he found life in normal society boring), hold a job, and form relationships. As a result of his civilian and enlisted
duties related to the outbreak of World War
II, he was unable to finish grammar school.
He was frustrated because the only jobs available to him were far below his capacities, because he had been unable to complete his
education. Furthermore, he had continuing
financial problems because he was incapable
of controlling his expenses adequately. He began participating in fraudulent activities as a
consequence of his thrill-seeking tendencies,
lack of impulse control, lack of fear, recklessness, and intense need to impress other people
by means of expensive clothes, cars, and so on.
While in prison, he responded to a relationship
announcement and began corresponding with
an intelligent and wealthy female psychotherapist. They became good friends and lovers, and
they married in prison. Mr. A was allowed (as a
result of good behavior) to spend the weekends
in the nice country house of his wife. Through
his wife he came in contact with well-educated
people who had a positive impact on his development, and in this setting his sense of authenticity could flourish. He discovered new
dimensions of his self. He learned very quickly
to discuss topics with his wife and her guests
on their level, and he incorporated elements
of their habits, gestures, and erudite lifestyles
that were attractive and appropriate to him.
His wife guided him through this process. He
distanced himself more and more from his
old attitude. He was soon motivated to finish
grammar school, and he then graduated with
honors from a university with a law degree.
Mr. A became a very talented lawyer and also
became very famous as an attorney of prominent white-collar criminal offenders.
Effective Components of
Introjective Identification Therapy
The effective components of Introjective
Identification are as follows: self-investigation and an increase of self-knowledge; social
comparison and correction of self-concept
and self; profound cognitive and empathic examination of another human being;
conscious rejection of undesirable features;
constructive self-enhancement activities; an
increase of authenticity, well-being, and happiness as a consequence of self-chosen and
self-realized positive change; and an increase
of self-esteem and self-respect. Imaginary
evaluation, connectedness, and interactions
with the idealized person are essential parts
of Introjective Identification Therapy, because these are the only ways to examine the
internal world of, and to create a bond with,
the idealized person. In addition, this might
bring the idealized individual to life in the
patient’s fantasy and own internal world.
Discussion
Identification process is necessary for preparation for many significant human activities
such as attachment, empathy, social-emotional and moral development, and social
interactions and adjustment. Introjective
Identification Therapy is intended as an additional component that could be used in
combination with other psychotherapeutic,
neurologic, and psychosocial treatment methods and psychological training programs. The
correction of self-concept, the stimulation of
increased self-knowledge and self-esteem/
respect, the growth of social-emotional and
moral capacities and of spiritual activities, the
gradual increase of responsibilities, and the
training of pro-social coping skills might be
significant and indispensable additional issues that should be realized in this approach
and other therapeutic approaches that are
combined with IIT. These are significant
correlates of improvement and remission in
persons with Antisocial Personality Disorder
(Black et al., 1995; Martens, 1997; Robins,
1966).
It is also important to investigate how
Introjective Identification Therapy can be
combined in an effective way with other therapeutic approaches, and which combinations
of approaches are most suitable in distinctive
situations (dependent upon co-morbidity, etiological factors, and so on). The author believes
that all kinds of psychotherapies can be paired
with Introjective Identification Therapy. The
combination can be realized by means of inclusion of IIT as an extra module in an existing therapeutic method, and the therapist can
decide on basis of motivation of the patient,
the nature of the patient’s suffering, and his or
her etiology and therapeutic progress if, when,
and how the IIT-module can be used. When
Positive Identification Therapy as a separated
discipline is combined with other therapies,
it requires the cooperation of two or more
therapists who will discuss at which stage of
the main therapy it might be effective to begin and terminate Introjective Identification
Therapy. In fact, different cooperation techniques have developed over the years in other
treatment programs, and special training programs exist to teach these techniques. These
techniques can be employed in the context
of uniting of IIT with other therapies (see
Henggeler, Schoenwald, Borduin, Rowlan,
& Cunningham, 1998).
It is time to initiate empirical studies to test
current theoretical explanations. Cultural,
religious, genetic, and neurobiological correlates of the identification process are also
not yet studied. Cultural and religious values, cultural and religious institutions, and
culture itself is interwoven with our life, and
cultural context plays an important role in
the development of individual social and behavioral characteristics and peer relationships.
Specifically, cultural and religious norms and
values may serve as a basis for the interpretation of particular behaviors (aggression,
sociability) and for the judgment about the
appropriateness of these behaviors (Martens,
2005b). The consequence is that our identification processes in an indirect manner might
be determined by cultural and religious influences. However, some personality traits (impulsivity, criminality, aggression or hostility,
lack of empathy, and lack of social adjustment or understanding), tendencies, socialemotional and moral (dys)functions, and
social perception/interaction capacities have
significant neurobiological and genetic correlates and might also have indirect impacts
on our identification processes. These cultural, religious, genetic, and neurobiological
correlates of the identification process should
be examined profoundly, because increasing
our knowledge about these influences can be
used for more adequate treatment and assessment programs and explanation models.
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About the Authors
Willem Martens, MD, PhD, is chair of the W. Kahn
Institute of Theoretical Psychiatry and Neuroscience and
is the advisor of psychiatry for the European Commission
(Leonardo da Vinci) and Ministry of Education, Culture,
and Science of the Netherlands. He is also a member
of the Royal College of Psychiatrists - Philosophy Interest
Group, UK.
CE ARTICLE 2: THE EFFECTS OF COLLEGE TENURE, GENDER, AND SOCIAL INVOLVEMENT ON ALCOHOL
DRINKING AND ALCOHOLISM IN COLLEGE STUDENTS (pages 18–24)
www.americanpsychotherapy.com and take the test for FREE.
LEARNING OBJECTIVES
1. List and explain the various risks and problems associated with alcohol consumption
among college students.
KEY WORDS: alcohol consumption, college students, gender, social
involvement
TARGET AUDIENCE:
PROGRAM LEVEL: Basic
2. Correctly describe the methods used to arrive at causal relationships.
DISCLOSURE: The authors have nothing to disclose.
3. Explain how gender is a predictor of alcohol consumption in college students.
PREREQUISITES: none
ABSTRACT
When opportunities to drink alcohol exist simultaneously with persistent social pressure, and when alcohol use is classically conditioned with pleasurable experiences such as dating and partying—
such conditions are likely to lead to social drinking and even alcohol abuse. College life consists of social encounters that involve alcohol and, consequently, may nurture behavioral norms that foster alcohol consumption. It is hypothesized that life in college promotes alcohol drinking and alcoholism tendencies in students, as they engage in essentially 4 or more years of “training” in alcohol
consumption.
Students (n = 168) at a conglomerate of small liberal arts colleges in Southern California were asked to fill out and return via mail self-report questionnaires concerning demographic information,
social involvement in college life, and alcohol drinking behavior. Results indicated that tenure in college predicted the development of alcoholism tendency. Specifically, social involvement was the
strongest predictor of alcohol consumption and alcoholism tendency, with gender also found to be a strong predictor of alcohol drinking behavior, particularly for males. Both social involvement and
gender provided reasons for college students to consume alcohol.
(Answer the following questions after reading the article, pages 18-24)
1. What are the risks and problems specifically associated with consumption of
alcohol among college students?
a) binge drinking and alcohol overdose
b) sexual assault, unplanned and unsafe sexual activity
c) disruption of higher order cognitive processes and poor academic performance
d) all of the above
2. What is/are the strongest predictor(s) of alcohol consumption in college students?
a) family history of alcohol abuse
b) level of academic motivation and grades
c) peer pressure and best friends’ alcohol drinking behaviors
d) all of the above
3. What were the methods used in the study to arrive at causal relationships in college alcohol drinking?
a) a comprehensive, multi-level analysis of the college population, factor-analyzed onto
the sample in a cross-sectional manner
b) a stratified, cross-sectional representative sample of the college population was
factor-analyzed and then entered into multiple regression analysis
c) none of the above
d) Both A and B
4. Which factors emerged from the results for reasons to consume alcohol in college
students?
a) the external social pressure to drink alcohol and the internal motivation to alter one’s
state of mind
b) the internal social pressure to drink and the external motivation to alter one’s state
of mind
c) Both A and B
d) none of the above
5.True or false: Men were found to more likely use alcohol, engage in alcohol consumption, and consequently become intoxicated.
a) True
b) False
6.True or false: Results from this study indicated that the probability of developing
alcoholism tendencies increases as students gain tenure in college.
a) True
b) False
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CE Article: 1 CE credit for this article
The Effects of College
Tenure, Gender, and Social
Involvement on Alcohol
Drinking and Alcoholism
in College Students
By Reuben Vaisman-Tzachor, PhD, FACFEI,
DAPA, CHS-III, and Judy Y. Lai, MS, MFT
Abstract
When opportunities to drink alcohol exist simultaneously with persistent social pressure,
and when alcohol use is classically conditioned with pleasurable experiences such as dating and partying—such conditions are likely to lead to social drinking and even alcohol
abuse. College life consists of social encounters that involve alcohol and, consequently,
may nurture behavioral norms that foster alcohol consumption. It is hypothesized that
life in college promotes alcohol drinking and alcoholism tendencies in students, as they
engage in essentially four or more years of “training” in alcohol consumption.
Students (n = 168) at a conglomerate of small liberal arts colleges in Southern
California were asked to fill out and return via mail self-report questionnaires concerning demographic information, social involvement in college life, and alcohol
drinking behavior. Results indicated that tenure in college predicted the development of alcoholism tendency. Specifically, social involvement was the strongest predictor of alcohol consumption and alcoholism tendency, with gender also found to
be a strong predictor of alcohol drinking behavior, particularly for males. Both social
involvement and gender provided reasons for college students to consume alcohol.
Factor analysis revealed different patterns of alcoholism tendencies for those of
pathological nature and those of socially disruptive nature. It further suggested various reasons for alcohol consumption, ranging from external social pressures to internal ones. Unfortunately, the present model could not adequately distinguish between
these factors due to multicollinearity limitations.
It was concluded that the propensity towards social involvement in college students
might simultaneously increase the risk of self-destructing behaviors—that is, alcohol
use and abuse. In addition, these potential byproducts may increase as students gain
tenure in college.
Introduction
Does a college education produce only better educated individuals or does it also promote alcoholism tendencies? The use and abuse of alcohol by
students have been identified as major problems
affecting college life (Carnegie Foundation for the
Advancement of Teaching, 1990). Although consumption rates vary among college campuses, high
alcohol use by college students has been repeatedly supported by numerous studies (HaworthHoeppner, Globetti, Stem, & Corasco, 1989;
Hughes & Dodder, 1983; Lo & Globetti, 1993),
with a reported consumption rate reaching as
high as 84% in a national survey of 140 colleges
and universities (Wechsler, Davenport, Dowdall,
Moeykens, & Castillo, 1994).
Various risks and problems have been associated with alcohol consumption. They include
drunkenness (Davison & Neale, 1986; Midanik
& Greenfield, 2000; Wechsler & Isaac, 1992),
alcoholism-related diseases (Carlson, 1986), alcohol-related traffic deaths (Zador, 1991), drunk
driving (Conger & Petersen, 1984; Jones, Peiper,
& Robertson, 1992), different forms of cancers
(Gross, 1988), impaired cognitive abilities (Carlson,
1986; Glass & Holyoak, 1986; Parker & Noble,
1977), lifetime sexual victimization (Burnam et
al., 1988; Winfield, George, Swartz, & Blazer,
1990), homicide (Murdoch, Pihl, & Ross, 1990;
Pernanen, 1991), domestic violence (Hamilton &
Collins, 1981), rape (Abbey, 1991; Abbey & Ross,
1992; Peraanen, 1991; Ullman & Knight, 1993),
and suicide (Jones et al., 1992). Consumption of
alcohol among college students has been specifically associated with binge drinking (Isaac, 1992;
Dowdall, Davenport, & Rimm, 1995; Wechsler,
1996; Wechsler et al., 1994; Wechsler & Isaac,
1992; Wilsnack, Wilsnack, & Hiller-Strumhofel,
1994), acute alcohol overdose (Hingson, 1998), sexual assault (Abbey, McAuslan, & Ross, 1998; Abbey,
Ross, McDuffie, & McAuslan, 1996; Goodchilds
& Zellman, 1984; Kanin, 1984, 1985; Koss, 1988;
Koss & Gaines, 1993; Mosher & Anderson, 1986;
Muehlenhard & Linton, 1987; Ullman, Karabatsos,
& Koss, 1999; Wechsler, Deutsch, & Dowdall,
1995), disruption of higher order cognitive processes (Leonard, 1989; Steele & Josephs, 1988; Steele
& Southwick, 1985), poor academic performance
(Cook & Moore, 1993; Hanson & Engs, 1992;
Wechsler, 1996; Wechsler & Isaac, 1992), as well
as unplanned and unsafe sexual activity (Presley,
Meilman, & Lyerla, 1993).
College and university administrators are increasingly concerned about the negative effects of
alcohol drinking in their communities (Baer et al.,
1992; Hingson, Berson, & Dowley, 1997; Kaplan,
1998; Marlatt, Baer, & Larimer, 1995; Straus &
Bacon, 1953). However, when alcohol becomes
(800) 592-1125
an important component in collegiate social activities (Gomberg, 1994; Johnston, O’Malley, &
Bachman, 1993; Rabow & Duncan-Schill, 1995;
Treise, Wolburg, & Otnes, 1999; Wechsler, 1996),
“having fun” may become the code of behavior despite emphases placed on academic success and intellectual enrichment. Particularly noteworthy is the
ironic contradiction between the declared objectives
of college educators and the destructive aspects of
alcohol consumption. Unfortunately, drinking alcohol may undermine the very intention of educational institutions to enhance and nurture students’ cognitive abilities and performance (Cook
& Moore, 1993; Hannon et al., 1987; Parker &
Noble, 1977).
College administrators have noted an increase in
students’ alcohol consumption with each successive
year in college (White, 1987; Wiggins & Wiggins,
1987; Straus & Bacon, 1953). Data supporting this
observation first emerged in a study by Straus and
Bacon (1953), who surveyed alcohol consumption
patterns in a large number of American undergraduate students. Wiggins and Wiggins (1987) obtained
similar results in a survey conducted at a southern
California university. White (1987) also found that
drinking-related problems for adolescents reached
their peak between the ages of 20 to 24, incidentally
the normative age range of many college students.
In general, activities that involve alcohol have
become a prevalent social norm in American society. Between the 1960s and 1980s, per capita
alcohol consumption in America rose steadily by
60% (Gross, 1988). Although the 1995 alcohol
sales data indicated that per capita consumption
of alcohol declined (Williams, Stinson, Sanchez,
& Dufour, 1997), no significant decreases have
been found on reports of social consequences or
dependence symptoms (Midanik & Clark, 1994;
Midanik & Greenfield, 2000). Reference group
theory has attributed the social context as the
most significant reason for the progressive increase
in alcohol use. From dates, parties, and holiday
celebrations to job recruitment, interviews, and
receptions (Conger & Petersen, 1984; Kaplan,
1998), students regularly encounter social gatherings that induce what is commonly referred to as
“social drinking” (Vogler & Bartz, 1982; Wiggins
& Wiggins, 1987). Both direct and indirect peer
pressure in such social events appear to influence
college students to consume alcohol (Hartford &
Grant, 1987; Rabow & Duncan-Schill, 1995). In
particular, drinking with best friends may serve as
a strong predictor of students’ drinking behavior
(Downs, 1987; Hannon et al., 1987). If greater
pressure from fellow peers may induce more conforming behavior, then conformity in college students may evidence itself in increased alcohol consumption.
TABLE 1
Descriptive Statistics of Variables in the Model of Alcohol Drinking Characteristics
Variable
Year in college *1
Student’s family annual
income
Gender
Ethnic/racial background
Mean
2.38
4.89
(80,000)
1.42
.80
S.D.
1.07
2.44
Minimum Value
1 year
1 (10,000/year)
Maximum Value
4 years
10 (180,000/year)
.50
.40
2 (male)
1 (Caucasian)
Social involvement scale *2
Reasons given for consuming
alcohol *3
Alcohol drinking behavior
score *4
Alcoholism tendency score *5
14.50
14.02
3.84
4.56
1 (female)
0 (African-American, HispanicAmerican)
5 (no social involvement)
5 (low social pressure)
25 (high social involvement)
25 (high social pressure)
5.13
2.50
3 (low alcohol consumption)
15 (high alcohol consumption)
13.52
4.52
8 (few or no symptoms)
40 (many symptoms)
1 Year in college: freshman, sophomore, junior, or senior.
2 Social involvement scale: Comprised of items that address the frequency of social involvement—including fraternity, sport
teams, parties, and dates.
3 Reasons given for alcohol consumption: Comprised of items that offer explanations for consuming alcohol -including to
unwind, be less shy with members of the opposite sex, and alter state of consciousness.
4 Alcohol drinking behavior: A composite of self-report frequency and quantity of alcohol consumption.
5 Alcoholism tendency: Comprised of items that address classic alcoholism symptoms—including drinking alone, drinking in
the morning, getting drunk before the party begins, and hangovers interfering with duties.
The notion that peer pressure may lead to alcohol consumption has been supported by studies that
found a high correlation between subjects’ drinking
habits and that of their best friends (Straus & Bacon,
1953; Wiggins & Wiggins, 1987). For instance, if a
high percentage of varsity team members engage in
social drinking, the greater the likelihood that the
others will also consume alcohol (Christiansen &
Teahan, 1987). In general, peer pressure and best
friends’ drinking behavior seem to be the strongest predictors of alcohol consumption in college
students (Conger & Petersen, 1984). As compared
with students who abstain from alcohol, those who
drink are described as “more likely to engage heavily
in social activities” and “to have friends, particularly
best friends, who also drink alcohol” (Conger and
Petersen, 1984, p. 511). Thus, alcohol consumption
may be perceived as a learned social behavior via
classical conditioning and reinforcement (Conger
& Petersen, 1984).
The analyses conducted in this study differed from
those of previous studies in so far as they attempted
to clarify causal relationships. It was predicted that
if A) higher college status is linked to B) increased
alcohol consumption, it is because of an intervening variable C) increased involvement in social activities that serve alcohol. It was also argued that
the amount of time spent in college determines the
extent to which students engage in social activities
involving alcohol. In accordance, reference group
settings that socialize students to use alcohol would
lead to greater alcohol consumption.
Method
Participants. A total of 300 undergraduate students
were randomly selected from a directory of 1,500
students attending private liberal arts colleges in
southern California. Because particular importance
was placed on the time spent in college, efforts were
made to include proportional numbers of students
from each college level, which consisted of freshman,
sophomore, junior, and senior. Out of 350 seniors,
70 were selected; out of 395 juniors, 79 were selected; out of 375 sophomores, 75 were selected; and
out of 380 freshmen, 76 were selected.
The sample consisted of 168 students who returned the completed questionnaire packet, an overall return rate of 58%. In terms of gender distribution, the sample was comprised of 73 men (44%)
and 93 women (56%), proportionally comparable
to the population of 707 males and 793 females. In
regards to the college level, the sample included 44
freshmen, 45 sophomores, 47 juniors, and 30 seniors. In comparison with the student population,
the sample was a rough representation of the proportional distribution by college class. The age distribution in the population ranged between 18 to
23 years old. Because more than 55% of the subjects
were between the ages of 19 and 20, the sample was
further representative of the population in its age
composition.
Subjects’ total annual family income was normally
distributed around a mean of $80,000 to $99,999
per year, for both parents combined. The standard
deviation of 2.4 closely approximated the distribution in the population. The ethnic/racial background
of the sample consisted of 79% Caucasian, 10%
Asian, 6% Hispanic, and 2% African American.
Again, this distribution was reflective of the population. Similarly, religious affiliation of the sample
cut along the same lines as the population, with
40% secular, 27% Protestant, 14% Catholic, 8%
Muslim, 7% Jewish, and 2% Buddhist.
Instrument. A uniform, 10-paged questionnaire
packet requiring approximately 10 minutes to complete was sent to all 300 subjects. The Likert-type
items addressed subjects’ involvement in social activities and alcohol drinking habits. Social involvement
was examined by items that inquired about membership and/or participation in social groups, including
fraternity/sorority activities, dormitory parties, dates,
and holiday celebrations. The indicators of alcohol
consumption consisted of questions involving frequency and amount of alcohol use, motivations for
drinking alcohol, situations in which alcohol is used,
and the frequency in which alcohol consumption led
to drunkenness. Standard demographic information
was also elicited, including socioeconomic status, year
in college, age, and race/ethnicity.
Procedure. Questionnaire packages were distributed through the inter-college mail system to all 300
sample addresses. Each packet contained a cover
letter from the researchers and a self-addressed and
stamped return envelope. After distribution of the
packages, two letters were sent to all subjects in 1and 2-week intervals, respectively, in order to rewww.americanpsychotherapy.com
mind and encourage participation. No personally
identifiable information was required, and neither
did the return envelope contain personally identifiable information.
TABLE 2
Pearson Product Moment Correlation Coefficients
And Amounts of Explained Variation (R square) in
The Model of Alcohol Drinking Characteristics
Variables
The Independent Variable in this study was the
subjects’ year in college—freshman, sophomore,
junior, or senior. The Mediating Factor was the
degree of social involvement, indicated by both
quantity and frequency of participation in social
activities. The Dependent Variables consisted of
the reported quantity and frequency of regular alcohol consumption at the time of survey. The dependent variables were measured via the tables by
Vogler and Bartz (1982) for calculating blood/alcohol levels and the DSM-IV (1994) list of alcoholism symptoms.
Hypotheses. A causal path was hypothesized, which
stated that the higher the college status, the greater
the social involvement and, in turn, the more reasons to consume alcohol. It was hypothesized that
maintaining more reasons to use alcohol would further result in greater alcohol consumption, followed
by a more extensive list of alcoholism symptoms.
Gender, socioeconomic status, and racial/ethnic
background were not hypothesized to be significant
predictors of alcohol consumption.
Statistical Analysis. To ensure internal consistency, all items in the measurement scales were factor analyzed. Items that did not yield loadings of
.40 or greater were excluded from the composite
(Zeller & Carmines, 1980). Multiple regression
data was derived using pairwise deletion of missing values, and all predictors were entered into the
equation at each corresponding causal level (Cohen
& Cohen, 1983).
Results
Descriptive Statistics. Table 1 presents the descriptive statistics of the sample for all variables in the
model. The calculated standard deviations indicated that sufficient variation existed in regards to all
variables to justify multivariate analysis.
Factor Analysis. Two factors emerged out of reasons
to consume alcohol. One emphasized the external
social pressure to drink alcohol, and the other the
internal motivation to alter one’s state of consciousness. Unfortunately, these two factors correlated to a
high degree, prohibiting further regression analysis,
which would increase the risk of multicollinearity.
Similarly, two factors emerged from the analysis of
alcoholism tendencies. Although one seemed more
pathological in nature, the other appeared more socially disruptive. These two factors also correlated
highly with each other, increasing the risk of multicollinearity with further multiple regression analy(800) 592-1125
Independent Variables
Student
income
Dependent Variables
Year in college -.095
-.045
Student
ethnic
race
-.041
Student
income
.056
.129*
.117*
.079
.008
.083
.107
.259**
.466**
.315**
.094
.088
.089
.058
.051
.546**
.390**
.281**
.762**
.597**
Student
gender
Student ethnic
race
Student
gender
Reason to
drink
Drinking
score
Alcoholism
tendency
Social
involvement
.022
.034
.124*
-.106
Reason to
drink
Drinking
score
Alcoholism
tendency
R square
.568**
.146*
.626**
.616**
.024
Significance:
* = < .05
** = < .001
sis. Factor analysis of the social involvement scale,
which consisted of public activities known to involve
alcohol, excluded factors containing the element of
personal preference, such as competitive sports and
artistic endeavors.
Correlations. Table 2 consists of the correlation matrix on which the model was based. Pearson product moment correlation coefficients between the
independent variable (year in college), the mediating variable (social involvement), and potentially
confounding variables (socioeconomic status, ethnic/racial background, and gender) are sufficiently
low to eliminate the potential suppressing effects of
multicollinearity (Zeller & Carmines, 1980).
Unlike most of the variables in this study, social
involvement did not have a sufficient amount of
variation. This was expected, as the social involvement scale was originally intended as a mediating
variable, and its predictors had no bearing on this
study. In regards to the two central dependent variables, statistically significant amounts of variation
were explained, particularly in the scales involving
alcoholism tendency and alcohol consumption. In
fact, the magnitude of R Square for these latter two
scales was shown to be atypical in social science research (Cohen & Cohen, 1983).
Regression Model. Figure 1 presents the regression
model developed in this study. Only significant Beta
values are marked in the model. Results confirmed
Social Involvement
Year in
College
.11*
.20
.48***
Alcoholism
Tendency
.26***
Gender
.34***
.64***
Income
.22**
Ethnic/Racial
Background
* = p < .05
** = p < .005
*** = p < .0005
“SOCIALLY ACTIVE
STUDENTS WERE
MORE LIKELY TO FIND
REASONS TO USE AND
CONSUME ALCOHOL,
AS WELL AS DEVELOP
CHARACTERISTICS
OF ALCOHOLISM
TENDENCIES.”
Alcohol
Drinking
Reasons for
Alcohol Drinking
.32***
that alcoholism tendencies develop with college tenure. However, the relationship between college tenure and social involvement failed to reach statistical
significance. As expected, results indicated that social
involvement is a salient determiner of all subsequent
dependent variables in the model. However, gender
was unexpectedly found to also serve as a strong predictor of alcohol drinking behavior.
Discussion
The results of this study confirmed most of the hypotheses set forth—that is, the higher the college
status and more specifically, the greater the social
involvement, the more likely college students were
to score high on alcohol indicators (i.e., having reasons to consume alcohol, engaging in alcohol drinking behavior, and exhibiting alcoholism tendencies).
Such outcome was noted regardless of socioeconomic status or racial/ethnic background. Results
also indicated that being a male college student was
a particularly good predictor in developing reasons
to use and consume alcohol. The findings showed
that college students with highly active social lives
tended to experience greater social pressure to consume alcohol, as compared with their less socially
active counterparts. Socially active students were
more likely to find reasons to use and consume alcohol, as well as develop characteristics of alcoholism
tendencies. Because social involvement continues to
be highly valued by college students, it may be important that school administrators and policymakers seek to address the potentially ill effects of social
involvement on students’ health and behavior. In
order to affect students’ drinking behaviors, it may
also be important to acknowledge their prevalence
and learn about their predictors.
Particularly strong relationships were found between A) having reasons to drink alcohol, B) alcohol
consumption, and C) development of classic alcoholism tendencies. These relationships have not been
clearly established in previous research on alcohol
for this specific population. Nevertheless, the effects
were expected. Students in a competitive college environment who have reasons to drink alcohol will
typically do so, thereby risking the development of
alcoholism tendencies.
A key hypothesis in this study obtained only limited confirmation—that is, number of years in college
was not found to be consistently and significantly
related to social involvement and alcohol indicators. It might be that college status is related in a
non-linear manner or at similar levels across all college years. This relationship, however, was implicitly
confirmed by other paths discovered, notably one
that predicted an increase in alcoholism tendencies
with college tenure. In other words, higher classmen
were more likely to exhibit alcoholic symptoms, such
as drinking during morning hours, suffering more
from hangovers, and drinking alcohol while alone.
Of all the effects of tenure in college, this result
was perhaps the most unfortunate and distressing.
It may be that students encounter greater pressure
to succeed academically with each subsequent year
in college, such that it becomes increasingly difficult to admit to deviant academic behavior, including alcohol consumption. It may also be too painful to acknowledge the intensified need to consume
alcohol, and furthermore, the active actualization
of this need. Whereas students in general may tend
not to admit to alcohol-related characteristics, upper classmen may particularly encounter difficulties
acknowledging symptoms of alcoholism.
Gender was unexpectedly found as a predicting
factor in the model. Whether due to external or
internal pressure, men were particularly found to
have reasons to use alcohol, engage in alcohol consumption, and consequently become intoxicated.
Perhaps males use alcohol more readily than their
female counterparts because they find the pressure
of a competitive college environment more taxing.
As predicted, neither students’ socioeconomic status nor racial/ethnic background impacted the alcohol
consumption patterns found in this study. Consistent
with data from previous studies, results also contradicted the prevalent stereotypes that associate alcoholic tendencies with those of lower socioeconomic
status, as well as racial/ethnic minority. According to
the present data, those of minority status and lower
socioeconomic background are just as likely as their
Caucasian and higher income counterparts to abstain
from or pursue alcohol consumption.
Summary and Conclusion
Results from this study indicated that the probability of developing alcoholism tendencies increases as
students gain tenure in college. Furthermore, social
involvement was consistently and strongly linked to
all alcoholic characteristics, including higher alcohol consumption and greater need to
use alcohol. Peer pressure and best friends’
drinking habits also served key elements in
the social environment of college life. Social
activities, though highly valued, may thus
foster the development of alcoholism in college students.
Results pointed to the importance of considering existing policies regarding alcohol
use on college campuses. It is very likely that
liberal policies regarding alcohol use may contribute to the development of alcoholism in
students. The present data denoted the ease
by which alcohol consumption becomes incorporated into the social routine and, moreover, the ease by which normal use becomes
abuse. Results exemplified how college communities, by embedding social reward within
a highly competitive environment, may nurture and promote alcohol use and abuse. Social
involvement appeared to be a powerful factor
in fostering such self-destructive behaviors.
Important policy questions emerged out
of this study. The most noteworthy conflicting choices confronting college administrators may be the promotion of an egalitarian
environment and simultaneous curbing of
alcohol consumption. It is not clear to what
extent counseling and guidance programs
may aid students in dealing with the pressures of academic life and freedom to experiment with alcohol use. Should policies that
(800) 592-1125
curtail alcohol be enacted in fraternity and
sorority meetings? Should such independent
social groups be required to serve non-alcoholic beverages along with alcohol, in order
to introduce the principle of choice?
Due to the limitations of this study, additional research would be both necessary and
beneficial. Subsequent research should acquire a larger sample size, strive for a higher
return rate, and correct for attenuation due to
the sensitivity associated with the questions.
Finer measuring tools that enable a more
accurate distinction between motivations to
consume alcohol, alcohol-drinking behaviors,
and various kinds of social involvement patterns should also be employed. Nonetheless,
the effectiveness of the present research design and the data acquired speak for themselves. It is hoped that this study will serve
as a foundation for subsequent research.
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Abbey, A., & Ross, L.T. (1992). The role of alcohol
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Bumam, M.A., Stein, J.A., Golding, J.M., Siegel,
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(1988). Sexual assault and mental disorders in a community sample. Journal of Consulting and Clinical Psychology, 56, 843–850.
Carlson, N.R. (1986). Physiology of behavior. Boston:
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R., & Castillo, S. (1994). Health and behavioral consequences of binge drinking in college. Journal of the
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Wechsler, H., Deutsch, C., & Dowdall, G. (1995).
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The Chronicle of Higher Education, 41(31), B1–B2.
Wechsler, H., Dowdall, G.W., Davenport, A., &
Rimm, E.B. (1995). MA gender-specific measure of
binge drinking among college students. American Journal of Public Health, 85, 982–984.
Wechsler, H., & Isaac, N. (1992). Binge drinkers at
Massachusetts colleges. Journal of the American Medical
Association, 267(21), 2929–2931.
White, H.R. (1987). Longitudinal stability and dimensional structure of problem drinking in adolescence.
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Wiggins, J.A., & Wiggins, B.B. (1987). Drinking
at a southern university: Its description and correlates.
Journal of Studies on Alcohol, 48(4), 319–324.
Williams, G.D., Stinson, F.S., Sanchez, L.L., & Dufour, M.C. (1997). Surveillance report 43: Apparent per
capita consumption: National, state, and regional trends:
1977-95. Washington DC: Public Health Service.
Wilsnack, S.C., Wilsnack, R.W., & Hiller-Sturmhofel, S. (1994). How women drink: Epidemiology of
women’s drinking and problem drinking. Alcohol Health
and Research World, 18, 173–181.
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D.G. (1990). Sexual assault and psychiatric disorders
among a community sample of women. American Journal of Psychiatry, 147, 335–341.
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in the social sciences: The link between theory and data.
New York: Cambridge University. n
Earn CE Credit
Take CE tests for free online at www.
americanpsychotherapy.com or see the
questions for this article on page 17.
About the Author
Reuben Vaisman-Tzachor, PhD, FACFEI, DAPA, CHS-III, was born
in Israel. He obtained his doctorate in clinical psychology from
Alliant International University, California School of Professional
Psychology in Los Angeles, where he is currently an adjunct professor. He is a Fellow of the American College of Forensic Examiners, a Diplomate of the American Psychotherapy Association,
and is Certified in Homeland Security at Level III.
Judy J. Lai-Yates, PhD, MFT, is a licensed clinical psychologist. She
has a private practice in West Los Angeles. In addition to serving
local communities, Dr. Lai-Yates is committed to international
outreach. Other research areas of interest include assessing
neuropsychological sequelae in children with brain tumors as well
as issues related to diversity. More information can be found on her
Web site: www.Dr-Judy.com.
CE ARTICLE 3: FIBROMYALGIA AND ANTIDEPRESSANTS (page 26)
www.acfei.com and take the test for FREE.
LEARNING OBJECTIVES
KEY WORDS: fibromyalgia, antidepressants
TARGET AUDIENCE: physicians
1. List the ways that some antidepressants can alleviate the symptoms of fibromyalgia.
2. Name an antidepressant drug approved by the Food and Drug Administration for the
treatment of fibromyalgia.
3. List the methods utilized in the study of the patients with fibromyalgia.
PROGRAM LEVEL:
DISCLOSURE:
PREREQUISITES: none
ABSTRACT
The American College of Rheumatology classifies fibromyalgia as presenting with generalized body pains for 3 months and pain on palpitation of 11 of the 18 paired tender spots. The incidence between those aged 20–50 years is about 6%, but the percentage rises to 8% after age 80. It is more common in women than in men, and it is estimated that at least 30% of patients with fibromyalgia
can have co-morbid depression or anxiety (Nampiaparampil & Shmerling, 2004).
(Answer the following questions after reading the article, page 26)
1. The symptoms of fibromyalgia are:
a) chronic generalized pain
b) fatigue
c) several tender points
d) all of the above
4.The percentage of patients with fibromyalgia that can have co-morbid depressive
or anxiety disorder is:
a) 100%
b) 50%
c) 30%
d) 10%
2.The incidence of fibromyalgia between ages 20–50 is:
a) <1%
b) 2–6%
c) 6%
5.An antidepressant approved for fibromyalgia by the FDA is:
a) duloxetine
b) tricyclic agents
c) sertraline
d) venlafaxine
3.Fibromyalgia and Major Depressive Disorder are the same illness or of the same
group.
a) true
b) false
c) partially true
6.Treatment modalities of fibromyalgia include:
a) pain management
b) treatment of sleep and muscle spasms
c) treatment of co-morbid conditions
d) all of the above
800-205-9165.
Name:
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licensure level.
(800) 592-1125
State License #:
Phone Number:
Address:
City:
State:
Zip:
E-mail:
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Circle one:
check enclosed
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RX PRIMER
By Harpriya A. (Sonya) Bhagar, MBBS
Prescription Primer:
Fibromyalgia and Antidepressants
T
(SNRI), showed improvement in pain and disability
in fibromyalgia. This effect was not influenced by its
antidepressant and anti-anxiety effects (Sayar, Aksu,
Ak, & Tosun, 2003). In a 6-month, multicenter,
randomized, double-blind, placebo-controlled study
of 520 patients with fibromyalgia, duloxetine, another SNRI antidepressant, showed improvement
in the outcomes measured at 3 months and at 6
months (Russell et al., 2008). In 2008, duloxetine
was approved by the Food and Drug Administration
for treatment of fibromyalgia.
To summarize, antidepressants can usually improve the co-morbid depressive symptoms in fibromyalgia, but some can target the pain and disability
of fibromyalgia as well.
he American College of Rheumatology classifies fibromyalgia as
presenting with generalized body pains for 3 months and pain
on palpitation of 11 of the 18 paired tender spots. The incidence
between those aged 20–50 years is about 6%, but the percentage
rises to 8% after age 80. It is more common in women than in men, and
it is estimated that at least 30% of patients with fibromyalgia can have comorbid depression or anxiety (Nampiaparampil & Shmerling, 2004).
s Harpriya A. (Sonya) Bhagar
Treatment of fibromyalgia involves both pharmacological and non-pharmacological methods. Certainly
pain management is an important component of the
treatment, and several analgesics have been used.
Recently, pregabalin, an antiseizure medication, was
approved by the Food and Drug Administration.
Other medications may be used for muscle relaxation and sleep. Exercise, a low-stress lifestyle, acupunture, massage, and chiropractic techniques, are
some of the common alternatives to medications.
The role of antidepressant medications in fibromyalgia is not well understood. Antidepressants that
are selective serotonin reuptake inhibitors (SSRIs)
may not improve the pain symptoms of fibromyalgia, but they may improve co-morbid depression if
present (Littlejohn & Guymer, 2006). On the other
hand, some antidepressants can improve the core
symptoms of fibromyalgia, such as pain, sleep, and
disability, independent of their effects on mood and
anxiety. A randomized, controlled trial of with amitryptiline (a tricyclic antidepressant) and naproxen
(a non-steroidal anti-inflammatory drug) showed
that amitryptiline improved pain, sleep, fatigue
upon waking up, and tender point score in fibromyalgia (Goldenberg, Felson, & Dinerman, 1986).
In a small 15-patient study, venlafaxine, a selective
serotonin and norepinephrine reuptake inhibitor
References
Goldenberg, D. L., Felson, D. T., & Dinerman, H. (1986,
Nov.). A randomized, controlled trial of amitriptyline and
naproxen in the treatment of patients with fibromyalgia. Arthritis Rheum., 29(11), 1371–7.
Littlejohn, G. O., & Guymer, E. K. (2006). Fibromyalgia
syndrome: Which antidepressant should we choose. Curr Pharm
Des., 12(1), 3–9.
Nampiaparampil, D. E., & Shmerling, R. H. (2004, Nov.) A
review of fibromyalgia. The American Journal of Managed Care,
10, 794–800.
Russell, I. J., Mease, P. J., Smith, T. R., Kajdasz, D. K., Wohlreich M. M., Detke, M. J., et al. (2008, June). Efficacy and safety of duloxetine for treatment of fibromyalgia in patients with
or without major depressive disorders: results from a 6-month,
randomized, double-blind, placebo-controlled, fixed-dose trial.
Pain, 136(3), 432–44. Epub 2008 Apr 18.
Sayar, K, Aksu, G, Ak, I, & Tosun, M. (2003). Venlafaxine treatment of fibromyalgia. Ann Pharmacother., 37(11), 1561–5. n
Earn CE Credit
Take CE tests for free online at www.americanpsychotherapy.com or see the questions for this
article on page 25.
About the Author
Harpriya A. (Sonya) Bhagar, MBBS, is an
assistant professor of clinical psychiatry at Indiana University School of Medicine and is a member of the American Psychotherapy Association.
She can be reached at hbhagar@iupui.edu.
CULTURE NOTES
By Irene Rosenberg-Javors, MEd, LMHC, DAPA
The Work of Psychotherapy
O
ver this past
summer, I read
an article,
”Medication
Increasingly
Replaces
Psychotherapy, Study Finds,”
wherein the author, Denise
Gellene (2008), reported
that a study drawn from data
gathered by the National
Ambulatory Medical Care
Survey had shown that, “the
percentage of patients who
received psychotherapy fell
to 28.9% in 2004–2005 from
44.4% in 1996–1997.”
s Irene Rosenberg-Javors
(800) 592-1125
According to the research, “financial incentives were
weighted against psychotherapy ... reimbursement
for a 45- to 50-minute outpatient psychotherapy session was 40.9% lower than reimbursement for three
15 minute medication management visits.” An author of the study, Dr. Mark Olfson of the Columbia
University Medical Center, said, “Patient attitudes
might also be hastening the shift ... taking a pill may
look a lot easier to patients than psychotherapy, which
is more time consuming and may involve the regular
participation of more than one family member.”
The data dealt exclusively with psychiatrists. It is
not known if other mental health professionals are
being affected by the trend. Olfson pointed out that
the study “couldn’t determine whether patients who
needed psychotherapy were receiving it from other
mental health providers or going without treatment.”
Interim Chairman of the Department of Psychiatry
at Yale University, Dr. William H. Sledge, said that
“the report was worrisome ... although training in psychotherapy is a standard part of psychiatric training
... that know-how is in danger of becoming lost.”
What are the implications of this report for those
of us who practice psychotherapy? Has the “talking
cure” become obsolete, a waste of time and money,
impractical, and too slow for our nanosecond universe? Over this past year, I had an experience with a
new client that very much reflected the trend toward
“fast food therapy.” Client “X” came to the session and
asked me, “Just how long does this business of therapy
take?” She told me that she had no time to sit around
and go on endlessly about her parents and that she
wanted “fast results.” I told her that we needed to talk
about the meaning of therapy. She looked at me and
replied, “Talk? I don’t want to talk. I want to get rid
of this pain and forget about it.” Needless to say, this
was our first and last session. She asked for the name
of a psychopharmacologist, and that was the last time
I saw her. Often, I hear people ask, “Why not just take
a pill—who needs all this psychotherapy stuff?”
Hyped-up advertisements on television about the wonders of medication and the increasing emphasis on the
biology of mental disorders, combined with the pressure
of managed care, have altered how the public sees psychotherapy. Are these trends something to be concerned
about? The Chairman of the Department of Psychiatry
at the Stanford University School of Medicine, who
is also the President-Elect of the American Psychiatric
Association, has said that, “the trend was not necessarily bad ... it could be seen as a natural evolution, similar
to what is seen in other fields of medicine.” He further
observed, “Years ago, if someone had a herniated disc,
they had a very complicated surgical procedure and were
in traction for weeks ... fields change.”
However, he strongly has emphasized that “what
we don’t want to do is decide treatment based on
reimbursement.” And there’s the rub, so to speak.
Psychotherapy is costly. Indeed, according to this
study, “researchers found that patients who paid outof-pocket, generally the wealthiest patient group, were
more likely to receive psychotherapy.” So we are back
to the money issue and insurance reimbursement.
We know that for some people a combination of talk
therapy and medication has proven the best treatment
plan. Unfortunately, insurance companies are not convinced. Medication rather than psychotherapy is the preferred choice because the bottom line is cutting costs.
As mental health professionals, the issue of how
to make psychotherapy affordable, while at the same
time not diminishing our capacity to earn a living,
is quite a challenge. Many of my colleagues are no
longer willing to take insurance. They are strictly
fee-for-service. They have come to this place after
years of putting up with managed care’s relentless
concern over the bottom line. As a result, the financial demographic of their clients is now predominantly middle to upper-middle class, whereas
before, when they took insurance, their client base
also included those from lower income groups.
For many, there is no doubt that medication has
helped dramatically. But, if the trend toward medication to the exclusion of psychotherapy continues
as a result of insurance companies not wanting to
pay for psychotherapy, then our clients are not being served well. Medication relieves symptoms; it
does not necessarily remove the source of the disorder. That is the work of psychotherapy.
All of us in the mental health field need to become
advocates for affordable mental health care that includes psychotherapy, medication, and whatever
else will help those in need.
References
Gellene, D. (2008, August 5). Medication increasingly replaces psychotherapy, study finds. Los Angeles Times. Retrieved
from http://www.latimes.com/news/science/la-sci-shrink52008aug05,0,7966688.story?track=rss n
About the Author
Irene Rosenberg-Javors, MEd, Diplomate
of the American Psychotherapy Association,
Licensed Mental Health Counselor, is a psychotherapist in NYC. She is also Adjunct Associate
Professor of Mental Health Counseling, Mental
Health Counseling Program, Ferkauf Graduate
School of Psychology, Yeshiva University. She
can be reached at ijavors@gmail.com.
“Abagnale’s lecture may be the best oneman show you will ever see.”
—Tom Hanks
Frank Abagnale’s rare blend of knowledge and expertise began more than 40
years ago when he was known as one of the world’s most famous confidence
men. This was depicted most graphically in his best-selling book, Catch Me If You
Can, a film of which was also made, directed by Steven Spielberg and starring
Leonardo DiCaprio and Tom Hanks.
Mr. Abagnale has now been associated with the FBI for over 30 years. More than
14,000 financial institutions, corporations and law enforcement agencies use his
fraud prevention programs.
Make plans now to attend his featured presentation at the 2009 National
Conference!
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INTERVIEW
Understanding Tai Chi:
An Interview with Michael Gilman
s Michael Gilman
Michael’s eclectic interests, studies, and
teaching include Advita Yoga with Master Subramuniya (Michael was Master
Subramuniya’s personal chef), Hatha
Yoga with Swami Vishnudevananda (Michael taught Hatha Yoga at the Vishnudevananda Ashram), Zen Buddhism, Arica
(Michael taught Arica in Tucson), Trager Psychophysical Integration (Michael
taught for the Trager Institute), and Dependable Strengths ((Michael taught for
the Dependable Strengths Institute).
Michael Gilman, current president of the
International Society of T’ai Chi Ch’uan Instructors,
is a longtime teacher in the human potential movement. Gilman began his studies of Tai Chi Chuan in
1968 with Master Choy Kam-man in San Francisco.
Master Choy’s father, Choy Hok-peng, is credited
with introducing Tai Chi to America in the 1940s.
Master Choy taught the full Yang Style curriculum,
and that is the system that Michael still practices
and teaches.
The American Psychotherapy Association recently
conducted an interview with Mr. Gilman to learn
more about this unique art form.
1. For those readers who aren’t familiar with Tai
Chi, can you briefly explain what exactly it is?
Contact Michael Gilman
Phone: (360) 385-5027
E-mail: michael@gilmanstudio.com
Web site: www.gilmanstudio.com
When I am asked what Tai Chi is, I am reminded
of the story of the blind men who, never having encountered an elephant, are asked to describe what it
is. One touches the trunk and says, “An elephant is
like a large snake.” Another touches a leg, and says,
“No, an elephant is like a tree.” Another, touching
the flank says, “No, an elephant is like a wall.”
They are all correct, yet their individual answer
is incomplete due to their not having all the information necessary to make an informed decision.
Talking about Tai Chi Chuan is much like the elephant problem. Tai Chi Chuan is a very complex
art, with three main roots that go back hundreds,
if not thousands, of years into Chinese history. If
you ask someone who is interested in martial arts, he
might respond that Tai Chi is definitely an effective
self-defense system. If a person on a spiritual path
were asked, he would probably respond saying it is
a meditative art. And if someone who was involved
with health and wellness was asked, he might answer that it is a physical culture/healing practice.
All are correct, yet Tai Chi cannot, and should
not, be limited to one field of study. All of the roots
are of equal importance and make Tai Chi Chuan
one of the most popular physical activities in the
world.
The name, Tai Chi Chuan, literally means
Supreme Ultimate Martial Art. Today, in order
to gain popularity worldwide, the art generally is
known as “Tai Chi,” eliminating the word “Chuan,”
which means martial system. I can understand the
reason. Most people are not interested in martial arts
and would certainly turn their backs on this marvelous exercise. But to fully understand its evolution,
we must include the Chuan aspect.
The first root is the Martial Arts. People have always needed to defend themselves, whether from
animals, or other humans. China is a crowded place,
with much chance for confrontation. Many martial
systems evolved. Tai Chi Chuan, as a martial art,
emerged from the Taoist Wudang temple sometime between 500 to 1000 AD. The distant past is
clouded, partially because of the idea that mystery
and myth will add to its appeal. Because it was very
effective, it was passed from father to son and never shared with strangers. It was not until the introduction of guns that hand-to-hand martial arts lost
their effectiveness. At this time, in the early 1800s,
Tai Chi started to move into the general population
and gain popularity as a physical exercise.
The oldest root, going back several thousand
years, is Traditional Chinese Medicine (TCM), or
the health and rejuvenation aspect. The Chinese
have been using exercise to maintain wellness, cure
disease, and strengthen the body for many thousands of years.
TCM theory is based on the idea of balance—
balance in all aspects of one’s life. Overall fitness and
well-being is not just the absence of disease. It was
derived by a balance between the physical, mental,
and spiritual. TCM sees the whole person and uses
various modalities as a way to eliminate the blocks
in our system that tend to cause excess or deficiency. Balanced, relaxing exercise is one of the ways. I
remember one Tai Chi instructor telling the class,
“Don’t make your heart sweat.” This relates to the
Chinese belief that internal balance is favored over
physical appearance. This approach is quite different than the traditional Western idea of fitness.
The third root is Spiritual Development, namely
Buddhism, Confucianism, and especially Taoism.
These philosophical systems have played an important part in the lives of a majority of Chinese
people and their cultural development. The Taoists
look to what is natural, a blending with the forces of
the Universe, to achieve supreme health and a long
life filled with a strong feeling of contentment. In
much the same way that TCM achieves physical
health through eliminating tension and extremes,
Taoism eliminates beliefs as an obstruction to seeing reality. Meditate, relax, and find your inner balance; all will become clear. Decisions will be based
on seeing what is, not acting on how one thinks it
should be. The Taoists didn’t have a creed, an allpowerful God, or rules. Each person is responsible
for his or her own personal achievement.
The Taoists developed the philosophy of Yin and
Yang and Tai Chi. By observing nature, the Taoists
saw that nature was a manifestation of complementary opposites—day and night, up and down, hot
and cold, sun and moon, male and female, etc. It
is this interaction of forces or expressions of energy that cause movement, and movement indicates
life.
If we look at the yin and yang of weather, barometric pressure, there are two forces: high (yang)
and low (yin) pressure. It is the interaction of these
two forces that causes different conditions. For example, a light breeze is caused by only a slight difference between the yang or high pressure and the yin
or low pressure. A greater pressure difference might
result in high winds or even a hurricane. The greater
the difference of pressure, (the higher the high and
the lower the low), the greater the resulting movement of air.
The Taoists realized that health and long life was
influenced by this yin and yang theory. Chi (life
force) and blood moved in the same way and for the
same reasons that all the external natural forces do. If
their bodies and minds maintained a balanced state
and did not bounce between the extremes, health
and contentment would result. Tai Chi Chuan is a blending of relaxed exercise from TCM, non-action and a spiritual goal
from Taoism, and also self-defense skills. It is hard
to really separate these various roots, as they are
very twisted and co-mingled. The body needs to
be strong to fight off disease as well as intruders.
The mind must be clear to see the workings of the
Universe, as well as beginnings of an emotional
problem. The practices, studies, and exercises for
good health, martial skill, and spiritual attainment
are all the same.
2. How did you become acquainted with Tai
Chi? Please describe your particular background
(800) 592-1125
with the practice and how you got to where you
are today.
I was living in San Francisco in 1968. I was working
as a television director, under a lot of stress. I didn’t
have time for exercise. I was depressed and unhappy.
The Vietnam War was starting to affect the young
people. We marched, but it didn’t seem to be having
any effect. Most of us wanted change, personally,
and for the direction of our government.
I went to a large gathering of spiritual teachers,
called Meeting of the Ways. There was an abundance of wise people in San Francisco at this time.
I remember many of the presenters at this meeting—Alan Watts, Timothy Leary, Alan Ginsberg,
Yogi Bajan, Swami Satchitananda, and others. They
spoke, did some exercises, and led chants. None of
the messages resonated strongly with me.
At one point I noticed a group of people in a circle in one corner of the large hall. I went over and
saw what was going to change my life. In the circle
was a Chinese man wearing a uniform, doing slow,
graceful movements. I watched mesmerized, as the
movements continued for some minutes, unfolding, and changing in subtle and beautiful ways. I
was transfixed.
I learned that this man, Master Choy Kam-man,
was doing Tai Chi Chuan and would be starting
new classes in Chinatown shortly. I got a flyer and
knew I would attend. It was full steam ahead for me
since that moment in 1968. I gave up smoking, got
healthy, found balance in my mind, and developed
a sense of purpose. After 5 years of study, I was certified to teach, moved to Tucson, and started teaching.
In 1973, Tai Chi was not well known, especially
out of the large, coastal cities. It took lots of effort to
start classes and earn a living, yet I did. I taught over
1,000 people in the course of 8 years in Tucson. In
1981, I moved to a small rural town in Washington
State, Port Townsend. I built a studio for my teaching and have been teaching full time ever since.
Through the years, I studied with many different
instructors who helped me to clarify my intention.
In 1994, I was the Grand Champion at a major Tai
Chi tournament, never having practiced or trained
for the event. It confirmed for me that I was on the
correct path for my development. It gave me the
confidence to start writing articles for major magazines, and I published my first book in 1996. It was
well received. I followed with a second book on Tai
Chi in 1998. Both were translated into French and
Italian and are still in print.
Around 2000, I set up a Web site for my work, offering free online lessons. I now get millions of hits
each year, have students worldwide, offer instructors
training via the Internet, all while maintaining my
Along with directing the
Gilman Studio of Tai Chi
Chuan, Michael is the author of two popular books
on Tai Chi Chuan, has published numerous articles,
and produces a long running Tai Chi and Chi Kung
series for public television.
He also coordinates the
annual Labor Day Energetic Retreat in the Olympic National Park attended by people from all over
the U.S. and offers free
classes worldwide via his
Web site: www.gilmanstudio.com. His most recent
book is 101 Reflections
of Tai Chi Chuan, and his
first book, entitled A String
Of Pearls, is now in its second edition (the title was
changed to 108 Insights
into Tai Chi Chuan) and is
available in French and Italian translations. Both books
have proven to be popular for all people interested in the internal arts and
self-improvement. He has
also published many articles in Tai Chi Magazine,
produced various video
tapes, and written The Tai
Chi Manual, a study guide
for students and teachers of
the Yang Style of Tai Chi.
Michael has also been
much honored for his continued dedication to helping teenagers.
small, intimate classes in my home town. I also have
produced shows on Tai Chi and Chi Kung for television. They have been running, five times a week,
for the past 6 years. I also have almost 100 instructional DVDs offered at my Web site.
3. Annals reaches out to a large readership of professionals in the psychotherapy field. Can Tai Chi
be useful for therapists working with clients?
Tai Chi is a great tool for therapists. First, for
work on themselves. I feel people can only give
what they have. If the therapist isn’t centered,
the client will know it or soon realize it. If the
therapist is coming from a centered place deep
inside, a calm, relaxed place, the client will also
relax and open.
A person seeks help from a therapist because he
or she is out of balance on a physical, emotional, or
mental/spiritual level, or a combination of all three.
It doesn’t take long for the committed individual to
regain balance given the proper instruction in Tai
Chi. It has proven itself for hundreds of years to help
people on all levels, as it did for me.
It is my opinion that many mental health problems occur because the client is stuck in their head.
According to Tai Chi, the body/mind is a bioelectric
system. The universe is energy; the human body is
energy. If we could look closely enough inside the
body, we would see that there is nothing solid, only
energy. This energy forms itself into shapes with various functions, like digestive organs, the circulatory
system, thinking mind, etc. This energy moves and
collects in places where needed. When one
eats, for instance, the body heats up as the
energy moves to the digestive system. When
doing physical exercise, the muscles heat up
as the energy moves to them. When problem
solving, the brain lights up. This is all easily
proven with current technology.
So when I say a person is stuck in their
head, it means that much of their energy is in
the head and they are top heavy, out of balance. It is as if the television set is on and the
person can’t figure out how to turn it off.
Tai Chi study is designed in such a way
that the energy system of the body is rooted
and grounded at the beginning. We concentrate on the health and healing aspects
of the art. Because most people seem to be
top heavy, thinking too much, they are out
of balance. It is like a pyramid placed upside
down. It wouldn’t take much to cause it to
fall. In the beginning stages, we turn the pyramid back onto its base. We build support
from the ground up, allowing relaxation and
a sense of the earth providing the support.
The earth in Chinese medicine is the mother,
the source of nurturing energy needed to feel
confident and loved.
After the body is rid of self-limiting, physical manifestations of past problems, the student then works on building strength, flexibility, sensitivity, awareness, mind/body
communication, and an understanding of
the martial root of the form.
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Finally, when the body/mind is healed and
strengthened, the student learns to transcend
the body and unify with the life force. Tai
Chi becomes Chinese spiritual philosophy
in action.
There is a saying in Tai Chi. “To know yourself is wisdom, to know others is enlightenment.” The first few years of Tai Chi study,
students learn about themselves—the correct
functioning of the body and mind. Only when
one has mastered himself, do we move the students into situations where they have the opportunity to understand other people at the
deepest, energetic level. The Tai Chi classics
state this simply. “When the opponent (other
person) is still, I am still. If he moves, I move
first.” This implies the complete openness of
the body/mind and sensitivity to the energetic
field surrounding all of us. This is the ultimate
goal of all martial artists, healing masters, and
spiritual teachers.
4. What sorts of general health benefits coincide with a scheduled Tai Chi regimen?
If we look at what it would take to be a successful martial artist, or athlete, that is what
we can expect. As the body is strengthened
and rooted, blood pressure is stabilized.
The arteries and veins open as inner tension is reduced, improving circulation, taking much stress off the heart. Circulation
also improves vision and hearing. Because
the circulation improves, the lymph system improves, so colds, flu, and other viral and bacterial invasions are lessened or
eliminated. Joints are exercised, without the
damaging effects of heavy impact. Bones
are strengthened because the slow, relaxed
movements are done in a semi-squatting
stance, and the weight is placed on one leg
at a time. Breathing is slow, relaxed, and
controlled in Tai Chi practice so the lungs
can clear and function at their maximum.
The mind is focused at all times on the
here and now, eliminating internal chatter and distractions. One becomes present
and able to see a situation more clearly.
Posture is improved by strengthening and
aligning the spine, thus eliminating many
back problems.
There are many special exercises in Tai Chi
study that involve moving energy consciously
inside the body. Many involve working with
the internal organs—cleansing toxins and
strengthening the function and interaction
between the various organs. This idea might
be quite foreign to most westerners but has
been practiced in the East for many thousands of years.
Tai Chi is typically regarded as a general,
tonic exercise. It helps the entire body in a
very balanced way. For special problems, the
Chinese tend to use Chi Kung, as it can be
more directed toward specific targets.
5. Tai Chi is often seen as a means to
achieving overall wellness. Along with
the physical health benefits, will Tai Chi
help to reduce psychological problems in
any way?
My own story illustrates many of the ways a
person can benefit psychologically from Tai
Chi practice. I was depressed because I had
too much stress and didn’t have a physical
outlet to help balance that destructive energy. I was in a very negative state, filled with
worry about the future. I felt uncomfortable
in groups, mostly comparing myself with
others. My mind would not shut down. I
couldn’t hear what people were saying to me
through all the mind chatter. I was ready to
end my life. I just couldn’t see a way out of
the pain.
My practice quickly helped me to feel better physically. That was an important step.
The physical imbalance is easiest to cure. It
gives a person a bit of room to take a breath
and start to relax. Non-stressful, easy, relaxing exercise sooths the body and mind.
The rooting and grounding exercises of
Tai Chi allow the emotions to become more
stable. The highs and lows become less extreme. There is a very strong sense of Self
developed, along with a strong sensation of
being centered in the body.
The mind is calmed because, most of the
time, the practitioner focuses on the body
center, located in the lower belly. The communication between the body, emotions, and
mental functions is strengthened through
constant, conscious movement of energy between these three centers.
In the usual group-learning situation of a
Tai Chi class, students learn to interact with
others on all levels. Students learn to touch
others and be touched in appropriate ways
and to receive the support of others. Students
learn to work together to achieve goals, to
understand their inner workings, and to notice the energy of others. The student’s focus
moves from me to us. He or she welcomes
and actually absorbs the energy of the partner. The final stages of Tai Chi study encourage the senior students to help others who
are making their way along the path of selfdiscovery. This leads to compassion and a
caring for others. The individual has moved
from isolation into a community of people
whose goal is enlightenment and openness
for the good of society. The thought pattern
has moved from me, to us, to all of us.
6. What sorts of participants typically visit
the studio? Is Tai Chi for everyone?
I live in a fairly unique place in the United
States. There is a high concentration of retired people who are health conscious and
have the time for study and practice. I offer
two main types of classes—Chi Kung and
Tai Chi Chuan. The Chi Kung (Energy exercises) classes appeal to the people who are
attracted to more traditional exercise programs, but with less stress and effort required.
The ages tend to range from the 40s to 80s,
mainly women. These students mostly come
every morning for a non-stress workout to get
their energy moving and to get centered for
the rest of the day.
The Tai Chi Chuan classes appeal to the
younger, 20s to 60s, group. Many come only
once a week to class and then practice on
their own the rest of the time. Tai Chi is more
demanding physically and mentally, so the
student is more committed. I make it clear
from the start that learning Tai Chi requires
a minimum of a year and is really a lifelong
study and practice. Also the martial aspects
appeal more to the younger fitness group.
It has been my practice to offer free classes
to all people of high school age. On occasion,
I offer an after-school class for teens. It is fun,
and the young people are enthusiastic. Most
of them have a hard time carrying through
with all that is required to completely learn
the system, as their lives are so busy. I have
had a few teens that have stuck with it and
have gone on to teach. That really brings me
a feeling of satisfaction, to be a part of their
possible future career. I always thought that
Tai Chi was for everyone because I enjoy it so
much. I have come to realize that many people are just moving through life too quickly
to take the time to learn something as complex as Tai Chi.
7. Michael, thank you for your time. Are
there any last words you’d like to leave
with our readers? How about advice for
first-time Tai Chi participants?
Thank you for this opportunity to share with
your readers some of my ideas about Tai Chi.
Tai Chi is a vast study, and like the elephant
story, I can only tell you about it from my
perspective, which will be different from
other teachers and practitioners. For people
who are interested, use the Internet. It provides all the information, plus more, that a
person would need to find out about this ancient Chinese system.
If one decides to attend a class, make sure
to sit in on a session before committing to a
lengthy program. Each teacher has a different
way of approaching the art, and as wonderful as the teacher might be, it might not be
the information you need to accomplish your
goals. If you are young, you probably won’t
want to be in a class with all seniors. If you
are looking for a meditative approach, make
sure the instructor isn’t a martial arts instructor from some different type of school, like
karate, who has taken one Tai Chi class and
now teaches it. Check on a teacher’s background, how he or she learned, and how
long it took before gaining an instructor’s
certificate. All this really makes a difference
in what and how you will learn. n
EXPERT PANEL
Substance Abuse in Adolescents
s Dr. Marino Carbonell
s Dr. James Ballard
s Dr. Richard Ponton
Dr. Marino Carbonell, EdD, LMHC, CAP, ICADC, is the founder and director of the South Miami Hospital
adolescent addiction treatment program and is now in private practice. His focus is helping adolescents and
families deal with substance and alcohol abuse, parent/teen conflict resolution, stress, and anxiety. He also
works with the adult population in dealing with all types of addiction disorders and treatment, family systems, and relationship dynamics. He is a Life Fellow of the American Psychotherapy Association.
Dr. James Ballard, DMin, CRT, is an Academy Certified Master Chaplain-III with the American Psychotherapy
Association. He received a Master of Divinity Degree and a Doctor of Ministries Degree from Southeastern
Baptist Theological Seminary. A charter member of the American Association of Christian Counselors, he is
also a member of the Association of Couples for Marriage Enrichment.
Dr. Richard Ponton is the Director of Human Services for the Township of Ocean in New Jersey. He is a Fellow
of the American Psychotherapy Association and currently serves on the Editorial Advisory Board.
Dr. Marino Carbonell: A recent dramatic finding
in neurobiological research may greatly increase the
understanding of young adult decision making and
the ability to help this age group choose wisely regarding drug abuse. This finding suggests that the
young adult brain is still developing physically, and
further investigation can answer some of the cognitive issues affecting the appeal of and decision to
use drugs. As professionals in the field of substance
abuse, what areas should we be focusing on to be
further investigated?
Dr. James Ballard: Family of origin—dysfunction breeds pain psychologically. To really treat
teen addictions, you must look at the foundational roots. Inner pain from abuse—sexually or
relationally, abandonment, divorce of parents, and
step-parenting are a few of the areas needing to be
focused on.
(800) 592-1125
Dr. Richard Ponton: When the Partnership for a
Drug Free America first aired the famous egg-frying,
“This is your brain on drugs” spot in 1987, there
was some skepticism and a few snide parodies …
however they seemed to get it right. We have learned
so much in the last 20 years about brain function
as a result of new technology … we could call neuroscience the frontier within. The new information
supports several general principles:
• The adolescent’s brain is developing at a rate
similar to that of prenatal and infancy periods.
• The impact of alcohol on the adolescent brain
is greater than on the adult brain.
• The adolescent’s brain is oversensitive to damage from alcohol and undersensitive to warning signs.
We have found in our program that teaching
youth about the very real impact of alcohol and
drugs on the brain is valuable in that it provides
information toward motivations. Providing parents
through a magnificent, yet not entirely predictable
process of firing and wiring (to use David Walsh’s
term). The conflict between the emotional “I want
to” and the rational “It’s not good” sometimes goes
to the former and stronger neural habits.
Dr. Marino Carbonell: There are no specific rules
for the current generic treatment of drug addiction.
More research needs to be conducted to understand
the best way to match treatment to patient. What
are some examples of therapies from your own experience that best match treatment to patient?
Dr. James Ballard: Teen Challenge.
“IDENTIFYING THE
CLIENT’S AWARENESS
OF THE PROBLEM
... ENABLES THE
COUNSELOR TO
WORK REALISTICALLY
TOWARD ATTAINABLE
GOALS WITH
THE CLIENT.”
with information is useful in helping them understand their teens’ behaviors and their own.
Dr. Marino Carbonell: Authors’ (Evans, 1998;
Johnson, 1995) review of the literature suggest that
young adults are ingrained with a relativistic (every
moral choice is equally valid and thus, can moral
choices really matter at all?) understanding of morality leading to drug dependency in some cases.
Does lack of moral choices in teens lead them to
abuse drugs?
Dr. James Ballard: Lack of moral choices in teens
can lead them to abuse drugs. Teens reflect those
around them. If they have been abused early on,
they have the proclivity to abuse others and drugs.
Drugs for many are taken not just for a chemical
high but also for management of emotional, relational, and spiritual pain.
Dr. Richard Ponton: Although it may be so that
many adolescents are morally relativistic, one must
wonder if that is a function of development or culture. The question of moral development is both
complex and rich in potential for the understanding of behavioral choices. Elliot Turiel has argued
that research demonstrates that young people can
and do make decisions not only on the basis of rules
and punishment but also on the basis of perceived
fairness and responsibility. That adolescents move in
this direction of decision-making is consistent with
the work of Kohlberg and James Rest. Why then, we
might ask, do they make such bad choices? One part
of the complex answer is suggested by brain development research. The pre-frontal cortex, the place
where we do our consequential thinking, is under
construction. The neural connections are formulated
Dr. Richard Ponton: An outstanding example
of treatment matching is found in the work of
Porchaska, DiClimente, and Norcross in their metatheoretical approach to stages of change. In working
with adolescents, this approach takes on even greater importance. Identifying the client’s awareness of
the problem, motivation for change, resistance to
change, and those resources available to the client
for such change enables the counselor to work realistically toward attainable goals with the client.
Dr. Marino Carbonell: Breaking the addiction cycle depends on the drug of choice. Some addicts try
to stop “cold turkey,” meaning the addict stops all at
once with no treatment. Another option is tapering
off, meaning that the addict gradually stops taking
drugs and may need some help to quit. Another
technique is taking a substance to help with the
addiction urge such as Antabuse (for alcohol) or
nicotine gum. A 12-step program or other support
group can help addicts deal with abstinence, and,
finally, intervention treatments (whether inpatient,
outpatient, community based, or private therapy).
Can the experts on the panel expand on the effectiveness of these treatment models? Is the 12-step
program still an effective model to prescribe?
Dr. James Ballard: No. I do not believe the 12-step
model works! Reasons. 1) 45% of those who attend
AA meetings never return after their first meeting.
2) 95% never return after the first year. 3) Their
own statistics reveal only a 5% retention rate. 4)
Although there are a number of spin-off groups, I
do not see the effectiveness now that they evidently
had years ago.
Dr. Richard Ponton: The research is clear and unequivocal in stating that addiction is a biopsychosocial disease, and many would add spiritual to that
holism as well. Thus, the various attempts to break
the cycle emphasize one or the other aspects of the
disease. I believe, that as we have found in all psychotherapy (see Nathan & Gorman, 1998), pharmacological approaches are useful in concert with
behavioral and cognitive-affective change.
Given the serious sequelae of adolescent
opioid addiction, many treatment experts
believe that buprenorphine should be the
treatment of choice for adolescent patients
with short addiction histories or those with
histories of multiple relapses. Because adolescents often present with short histories of
drug use, detoxification with buprenorphine,
followed by drug-free or naltrexone treatment, should be attempted first before proceeding to opioid maintenance. According
to the Substance Abuse and Mental Health
Services Administration, Naltrexone may be
a valuable therapeutic adjunct after detoxification. Naltrexone has no abuse potential
and may help to prevent relapse by blocking
the effects of opioids if the patient relapses
to opioid use. Naltrexone has been a valuable therapeutic adjunct in some opioidabusing populations, particularly youth and
other opioid users early in the course of addiction.
In considering the use of 12-step programs
for adolescents, several factors must be considered. The cookie-cutter approach that 12-step
programs help everyone flies in the face of the
data. While research on fellowship programs
provides some challenges, because of the anonymous and natural nature of the programs (the
key to their success), some research suggests
that about 80% of those who visit a fellowship do not return. That, by the way, is not all
that different from the research on single visits
to therapists’ office. A prescriptive approach
to the use of AA as an adjunct to treatment
suggests to professionals that we look to the
personality, social situation, and etiology of
the addiction in order to determine if AA or
another fellowship program would promote
the treatment and recovery process. I do not
hold the position of “Give it a shot, it couldn’t
hurt.” Indeed, if I place obstacles in the way
of recovery or set up barriers to the process, it
can hurt. In some cases, asking an adolescent
to commit to something for 90 days sets him
up for failure. Having kids try on AA or NA,
processing the experience with them, and allowing them to explore the program as a potential resource has proven successful in the
work we have been doing with kids.
Dr. Marino Carbonell: A study commissioned by the University of Texas Medical
Branch found that the psychological damage from physical abuse may play a role in
substance abuse. The results of this particular
study strongly support a positive correlation
between drug abuse and physical and sexual
(800) 592-1125
abuse. Does the panel support this assessment? What are some of the indicators that
would lead a child from one of abuse to an
abuser of drugs?
Dr. James Ballard: I support this assessment.
As I mentioned in an earlier question (2), indicators would include verbal, physical, or
sexual abuse in childhood, divorce of parents,
single parenting, abandonment, abuse of alcohol or drugs, availability of drugs in the
home environment, and peer pressure. These
are a few of the indicators of why youth turn
to drugs to face life.
Dr. Marino Carbonell: One of the ways to
treat young adult drug abuse is to modify
the cultural climate, focusing children to
value and achieve independence, adventure,
intimacy, consciousness, activity, and commitment to community among many other
things. What can schools and families do to
promote a healthy, drug-free lifestyle? Are
the programs in place such as D.A.R.E. and
Informed Families making an impact?
Dr. James Ballard: With our cultural climate
in a state of confusion, it is imperative that
families, schools, and congregations begin
to come to the forefront of modification of
society. Instead of being reactive, they must
become proactive. D.A.R.E. and Informed
Families are making an impact, but there
needs to be more such organizations, on the
community, state, and national level. Looking
at youth as a whole is imperative. Assisting
them by seeking personal involvement in
community-based programs must take center
stage in coping with the plague of pain.
Dr. Richard Ponton: I would argue that
there is a need to change the thinking and
conversation from programs to people. The
data from the Search Institute in Minnesota
is rich and informative. It suggests that there
are 40 developmental assets, some that are
within young people and some that are provided to them from the people around them.
The evidence is overwhelming to suggest that
the more of those assets young people have
… the less likely they are to use alcohol or
drugs or to engage in a variety of other highrisk behaviors. Beyond that, the more likely they are to thrive and demonstrate other
markers of success. In prevention and treatment we are focusing on strategies that increase those assets in the young people and
enhance the awareness of the role of the
school and the community in providing op-
portunities for asset development. D.A.R.E.
or any other program is not the answer. If the
D.A.R.E. officer becomes a source of strength
to the youth, if the D.A.R.E. program is in a
school that is a safe place to be in and where
the child is supported, empowered, and challenged, and if the teens leave D.A.R.E. and
go home to a place where there is both love
and limits, then we begin to provide a culture of resilience and thriving.
Dr. Marino Carbonell: The consequences
of failing to intervene early and failing to
provide age-appropriate substance abuse and
mental health treatment are substantial and
long term. However, there is growing evidence that successful early intervention and
treatment carries a significant benefit for the
individual and society. What types of early
intervention can be offered? What is the cost/
benefit of early treatment?
Dr. James Ballard: There should be a removal of temptation from their home—locking
up of pills, etc. Parents need to become aware
of behavior change—personality factors,
grade change, attention to sleep-wake cycle
or mood patterns, the possibilities of a level
of secretiveness or sneaking around.
The establishing of family rituals. There
are three major types of rituals according to
Drs. Merry Evenson and Glen Jennings at
the Texas Women’s University Department
of Family Services: 1) Family celebrations,
2) Family traditions, and 3) Patterned family interactions.
Such rituals stabilize the family in two aspects
of time: 1) In the here and now, rituals are an
anchor for the family. 2) Rituals also have the
power to link past, present, and future.
Rituals have five basic functions for both the
family and individual: 1) Reduction of anxieties. 2) Promotion of actions. 3) Resolution
of contradictions. 4) Promotion of relabeling.
5) Action as a protective device.
Dr. Richard Ponton: Although the issue of
cost effectiveness is a complex one (please
see the National Institute on Drug Abuse
Web site for a discussion of this), a very basic metric is the cost of higher vs. lower levels of treatment. The cost of inpatient residential treatment is on average more than
six times that of outpatient service (NIDA,
2003). This metric does not measure the cost
of missed opportunity, potential long-term
health consequences, and potential criminality associated with drug and alcohol use
as it continues.
So why is it that so often we miss the opportunity for intervention? Perhaps it is because we don’t quite understand what intervention is and who needs it. It has been said
that a good intervention presents reality in a
receivable way. In order for that to happen,
someone has to say, “Here is the effect of this
behavior on outcome.” It requires that alcohol and drug issues become the foreground of
the discussion, not the background. To mix
my metaphor, the good intervention tunes
the attention to alcohol and drugs like tuning in a radio station … to the crisp and clear
broadcast … “what is not working is your
use.” Intervention requires schools, police,
the courts, and the community to get on the
same page … because the less they are, the
more there is static in the message. The parents, too, have static. They don’t want to know
that there is a problem … indeed they can’t
know that there is a problem until they know
that there is hope for a solution. The tuning
process overpowers the static of denial and
hopelessness with the signal of information
and hope. In our community, every child who
is found to be involved in underage drinking
is sent by the police, the school, or the judiciary to a program we call EXPLORE. This
two-session program provides information to
the teens and assesses their patterns of drinking using a reliable and valid inventory. In the
second session, the program provides that information to the parents along with parenting skills and resources for treatment. Of the
youth who have been involved with this program, 50% have indicated a need for further
treatment and 75% of them have volunteered
for it.
Dr. Marino Carbonell: Deciding to send a
young adult to a residential treatment facility
is a family decision. Decisions are best made
when problems are identified, because by the
time parents consider residential treatment,
they have probably tried other methods.
However, teen centers have been focusing on
the age rather than the addiction. What factor should teen treatment centers focus on?
Should both factors matter?
Dr. James Ballard: The focus should be on
addiction above all else. Centers treating
addictions are now focusing more on problems rather than age. I offer the following
as examples:
1. Teen Challenge. Their Web site (www.
teenchallengeusa.com) describes the Teen
Challenge program and the services they
offer. Their programs, outreaches, and
presentations are geared toward both
teens and adults. It is one of the oldest,
largest, and most successful programs of
its kind in the world and has a distinctive
Christian philosophy that many congregations and faith-based organizations can
relate to. I have referred several youth to
them over the years and have been grateful for the ministry of Teen Challenge
and the recovery of these youth. I would
highly recommend them as a resource.
2. Saint Jude Retreat House established in
1992. It is a Social-Educational Alternative to conventional drug rehab and
alcohol rehab centers along with alcohol and drug treatment programs. They
have the highest independently verified
success rate in America. They are truly
confidential, cost effective, and the most
experienced non-12-step program in
America. Alcoholism and drug addiction
are learned behaviors and not a disease.
3. Teen Interventions—Help for the struggling teens. 1-800-840-6537.
4. Second Nature Wilderness Program. The
industry’s most sophisticated wilderness
therapy treatment program. They provide
insight, direction, and hope to troubled
teens and their families. Therapists and
other staff members assist the teens to discover reasons behind their actions. Teens
become students of themselves. They
then can make healthy choices regarding
the future. Second Nature understands
that many parents are not sure where to
go for help for their teen. They have an
entire staff of qualified individuals who
can provide solutions to questions regarding the needs of troubled teens or
parents’ needs. They can be contacted at
1-866-205-2500 or through their Web
site at www.SNWP.com.
Dr. Richard Ponton: Residential treatment
provides a unique option on the continuum
of care for adolescent substance abuse disorder.
The American Society of Addiction Medicine
has identified several criteria for admission to
residential treatment including emotional and
behavioral issues of moderate or high severity,
resistance of moderate or high severity, significant continued use or relapse and lack of success in lower levels of treatment, and an unsupportive or inconsistent recovery environment.
Successful use of inpatient treatment includes
such hallmarks as a positive approach to treating the whole individual, incorporation of the
family in the recovery process, the development of community resources for the young
person, and the establishment of a discharge
plan that includes aftercare.
Although I am not sure what you mean by
the focus of treatment centers on the age rather
than the addiction, I maintain that no addiction exists in a vacuum. The age, developmental
stage, family, and social network all affect the
addiction and, with the exception of chronological age, all are affected by the addiction.
Dr. Marino Carbonell: The low opinion of
treatment values held by young adults has been
shown to be a major cause of resistance to their
treatment, and this resistance is being constantly reinforced when young adults are placed in
same-age settings. Additionally, when assessing
young adult treatment facilities, one of the first
issues an individual confronts in caring for the
young adult patient is the issue of confidentiality. What are some suggestions that can address
and respond to this issue of confidentiality (or
lack of) in teen treatment therapy?
Dr. James Ballard: There are materials available in books to assist parents and counselors regarding confidentiality. Boundaries,
Boundaries With Teens, Boundaries in
Marriage—all written by Cloud and
Townsend—provide valuable assistance.
There are treatment facilities now available
that emphasize trust and confidentially. Note
statements in number 8.
Dr. Richard Ponton: It seems to me that if
we said that there was generally a low opinion
of treatment among heart patients, kidney patients, or clients with depression, regardless of
age, that would serve as a call to action to do
something different. I believe the same is true
for adolescent substance abuse treatment. It has
not been the experience of our program that
young people hold a negative view. In fact, in
our Intensive Outpatient Program, one of our
greatest sources of clients is referral from other teens who have been through the program.
There is simple reason for this. Treat clients
with dignity, respect, and kindness. When clients enter our program, we incorporate parents
from the outset … as positive resources in their
teens’ lives. In so doing, we make the case that
participation in the program requires the weekly
participation of the parents and a consent for release of information to the parents. The consent
is specific and limited so that both the youth
and the parents know what to expect.
Dr. Marino Carbonell: The research revealed
that teens with a higher degree of personal
devotion, personal conservatism, and institutional conservatism were less likely to engage
in alcohol consumption and other drug use.
This revelation is particularly significant because the onset of alcoholism and drug addiction usually occurs in adolescence. Discussion
from the expert panel: Is a well-developed
spiritual life a deterrent to addiction?
Dr. James Ballard: A well-developed spiritual
life is definitely a deterrent to addiction. We
have been created in the image of God—spirit,
soul, and body. Our inner beings, spirit and
soul, are eternal. We are housed in a temporal
body. As one thinks—so is he. Our thoughts,
actions, and feelings impact our physiology.
One who has committed his life to Christ is
a child of God. As the new identity is understood, a person has God’s presence living within. No longer does one have to be a victim of
the past or endure pain of the present. Where
there is a well-developed spiritual life in childhood with parents committed to the holistic
approach to parenting, it can enable youth to
see themselves as persons of worth and meaning. This will provide a powerful deterrent to
addiction. For additional information, you
may reach me at www.HealingTheHurt.org.
Dr. Richard Ponton: Thank you for this important and thoughtful question. There is a
significant body of literature discussing spirituality and religiosity. Although there is some
correlation of religiosity to conservatism, they
are not synonymous. We can suspect that
young people in more conservative families
and in more conservative communities are
less likely to use substances, have more support in their no-use decisions, are less anonymous and disconnected in their community,
and if they use, are more likely to start later.
Each of these is protective and none of them
are spiritual or religious in their essence. In
regard to spirituality, researchers have looked
at the protectiveness of a relational spirituality (that is, a belief in a relationship of meaning with God and/or the Universe). In an
interesting study from 2007, Knight et al.
found several constructs included in spirituality such as forgiveness, belief, daily positive spiritual experiences, and positive spiritual coping strategies to be associated with
lower alcohol use among teens. Conversely,
they found several religiosity variables such
as commitment, organizational religiousness,
and private religious practices to have a nonsignificant relationship to use or abstinence
from alcohol. Although this topic defies simplicity as much as it defies certainty, I suspect
one thing that protects teens from substance
abuse is their understanding of meaningfulness in their life and their role in the community and family. At is best, that is the role
of both spirituality and religion. n
Member Spotlight: Amy Flavin, MS, LPC, DAPA, BCPC
s Amy Flavin
Please introduce yourself in a
few sentences (background,
experience, etc.). I received my BA in German from DePauw
University in 1979 and was a high school German
teacher from 1979 to 1985. I then received
my MS in Counseling and Human Relations
from Villanova University in 1989 and became
Certified in Secondary School Guidance.
(800) 592-1125
I have 16 years of experience as a therapist
and have worked extensively with adolescents
and families. I have also been an adjunct professor at Nyack College in Manhattan for
the past 5 years. I teach Child Psychology,
Adolescent Psychology, Interpersonal
Communication, Adult Development, and
Family Counseling.
I frequently conduct seminars on mental health topics and have addressed issues
in child and adolescent psychology, parenting, eating disorders, the impact of divorce, depression, and suicide. I have been
a seminar speaker at National Youthworkers’
Convention addressing the topics of minding your family while in the ministry, mental health issues in the adolescent population, and adolescent development and
psychology.
I was also a seminar presenter at the
American Psychotherapy Association National
Conference in September 2008 speaking on
the topic of adolescent development and narrative therapy.
On a personal note, I am also the mother of two grown children (19 and 23), an
active member of my local church, and go
on yearly mission trips to Mexico to build
houses.
How has membership advanced
your career or practice? What do
you think is the most helpful
benefit of membership?
I have been a member of the APA for about
18 months and joined primarily for the opportunity to have access to the Annals and
the additional resources and continuing education that the association provides—I was
also looking for additional opportunities to
network with colleagues. I thoroughly enjoyed the national conference in San Diego
and feel that when a person is able to take
advantage of that it is a wonderful benefit of
membership to spend time with colleagues
and hear from some of the top presenters in
our field. Being a part of an organization that
is committed to professionalism and helping
me be the best that I can be is very helpful
and encouraging. I know that all of you work
hard at what you do to make that happen,
and I appreciate it!
If you are interested in being featured in our
Member Spotlight column, or would like to
nominate a colleague, please contact editor@
americanpsychotherapy.com. n
CURRENT ISSUES
Mental Health
Parity Bill
Passes Through
Legislation
This has been a
historically momentous year for mental
health coverage as the
legislature achieved
passage of a landmark
law to bring mental
health parity protection to more than 100
million Americans
covered by group
health insurance.
Celebrating
MENTAL HEALTH
PARITY!
Simply put, parity means equality. For many
years, therapists and other mental health
professionals have lobbied to place mental health coverage on a level playing field
with physical health coverage. Although
there are obvious differences between lifethreatening physical illnesses such as cancer and mental illness, it has been proven
time and time again that mental illness and
addictions can be just as damaging.
The American Psychotherapy
Association recently conducted an in-
s Former Attorney General John Ashcroft, former House Speaker Newt Gingrich, Dr. Robert O’Block, founder
of the American Psychotherapy Association, and Congressman Roy Blunt
terview with our Washington D.C. Liaison
and member Linda Whitten Stalters,
who lobbied for mental health parity.
1. This is an enormous milestone for the mental
health field. What does this legislation mean for
Americans?
This has been a historically momentous year for mental health coverage as the legislature achieved passage
of a landmark law to bring mental health parity protection to more than 100 million Americans covered
by group health insurance. Passage of the Mental
Health Parity and Addiction Equity Act is a comprehensive parity legislation. This legislation applies
to all group health plans with 51 or more employees, 82 million individuals in self-insured employer
health plans that are not governed by state parity
laws, and another 31 million in plans that are subject to state regulation.
Except to the extent that a state parity law requires
broader coverage, the legislation imposes no requirements as to what conditions must be covered, and
whatever is covered must be at parity with medical
coverage. It prohibits group health plans that offer
coverage for mental health and substance use conditions from imposing treatment limitations and financial requirements on those benefits that are stricter
than for medical and surgical benefits. It covers the
full range of mental illnesses, including major depression, bipolar disorder (manic-depression), schizophrenia, and anxiety disorders, and it will strengthen the 1996 law by prohibiting unequal limits on
annual or lifetime mental health benefits, inpatient
hospital stays, outpatient visits, and out-of-pocket
expenses.
(800) 592-1125
s Former American Psychotherapy Association Chief Association Officer Brent McCoy and Linda Whitten
Stalters at a parity rally in Washington D.C.
s Daphne Greenlee, Congressman Roy Blunt, and Dr. Robert O’Block, founder and Chief Executive Officer of
the American Psychotherapy Association, met to lobby for mental health parity.
Linda Whitten Stalters,
APRN, BC, FAPA, is Chair of
the Board of Directors of the
Schizophrenia and Related
Disorders Alliance of America (SARDAA). SARDAA was
organized to continue ongoing support for Schizophrenics
Anonymous, create a national
toll-free hotline, provide information via its Web site (www.
sardaa.org), promote personal
stories of recovery and hope,
and organize a speaker’s bureau of people with expertise
about living with the disease,
family issues and care professionals. SARDAA’s focus is on
providing materials and information that will assist people
in their own personal journey
in living with their illness.
4. Is this fight now over? Are there any other obstacles that still stand in the way of complete parity?
Contact Linda Whitten Stalters
at linda.stalters@sardaa.org.
s Linda Whitten Stalters
APA’s Involvement
Over the past 6 years, the
American Psychotherapy
Association has played
an active part in lobbying
with congressional leaders to contribute to the efforts to forward the Mental
Health Parity Law. Dr.
Robert O’Block, with
the staff of the American
Psychotherapy
Association, has formed
coalitions with several lawmakers and activist groups
to promote the needs of our
members.
We continue to pledge
our dedication and effort to
promote and speak out on
behalf of our membership.
A plan offering out-of-network benefits for medical/
surgical care must also offer out-of-network coverage for mental health and addiction treatment and
provide services at parity.
This legislation preserves strong state parity and
consumer laws. State parity laws vary widely from
state to state.
Mental Health America provides a great overview
of States’ Parity: http://takeaction.mentalhealthamerica.net/site/DocServer/Parity_Chart_2008_1_.
pdf?docID=1161
2. Will the inclusion of mental health services
raise insurance premiums?
The Congressional Budget Office (CBO) has estimated that the Act will raise health plan premiums by an
average of about 0.4 percent, to be split between employers and their employees Cost exemption allows
a health plan to be exempted from the federal parity
law if it can prove that parity is raising its total plan
costs by more than 2% in the first year after enactment of parity law and 1% thereafter. Plans must first
implement parity for at least 6 months.
This legislature eliminates the higher out-of-pocket
costs for mental health treatment than other illnesses,
thus it can potentially reduce out-of-pocket costs.
3. Who will likely benefit from this? Who will
not benefit?
As cited previously, this benefits employees enrolled
in group health plans with 51 or more employees.
Children and adults with a mental illness (brain disease/disorder) will benefit. Employers whose overall
productivity is adversely affected by untreated mental illness will benefit.
Appropriately implementing this legislature will
take time. The law is to be implemented by January
2010.
The new Administration and Congress must be
kept aware of the priority for mental health treatment. We must continue to educate our legislators.
It has been my experience that mental (brain) illness
is widely misunderstood. One legislator remarked,
“We can’t increase mental health coverage because
mental illness is more frequently being diagnosed.”
My retort is, “When other diseases are more frequently diagnosed, do we stop treating the newly
diagnosed?”
This legislation only addresses employee group
health insurance of a workforce of 51 employees
or more. The Medicare Improvements for Patients
and Providers Act of 2008, another crucial legislative victory toward ending discrimination against
people with mental health needs, was passed July
15th of this year. The legislation will phase out the
inequitable 50 percent co-pay requirement for outpatient mental health care under the Medicare program. This longstanding discriminatory practice has
helped to maintain stigma.
These are breakthroughs but not an end. We can
look forward to the day when people with mental
health (brain) conditions are viewed as no different
than people with any other health condition.
Mental Health Legislature in the Works
Summaries written by the Congressional Research
Service:
Community Mental Health Services
Improvement Act (S. 2182) and CommunityBased Mental Health Infrastructure
Improvement Act (S. 2183)
10/17/2007—Introduced
Community Mental Health Services Improvement
Act—Amends the Public Health Service Act to require the Secretary of Health and Human Services
to award grants for: (1) services to children, adults,
and older adults with mental illnesses who have
co-occurring primary care conditions and chronic
diseases through the co-location of primary and
specialty medical care in community-based mental and behavioral health settings; (2) programs to
address behavioral and mental health workforce
needs in professional shortage areas; (3) expanding
behavioral and mental health education and training programs; (4) tele-mental health in medically
underserved areas; and (5) developing and implementing a plan to ensure that the National Health
Information Infrastructure meets the needs of mental health and substance abuse providers.
Community-Based Mental Health Infrastructure
Improvements Act—Amends the Public Health
Service Act to authorize the Secretary of Health and
Human Services to award grants to eligible entities
for the construction or modernization of facilities to
provide mental health and behavioral health services
to individuals. Defines an “eligible entity” as: (1) a
state that is the recipient of a Community Mental
Health Services Block Grant and a Substance Abuse
Prevention and Treatment Block Grant under such
Act; or (2) an Indian tribe or a tribal organization.
• Includes among grant application requirements
assurances that facilities will be used for not
less than 10 years for community-based mental
health or substance abuse services for those who
cannot pay for such services. Permits a grant recipient to request permission to transfer such a
10-year obligation to another facility.
• Authorizes a state that receives a grant to award
a subgrant to a qualified community program
for activities such as: (1) the construction, expansion, and modernization of mental and behavioral health facilities; and (2) the construction and structural modification of facilities to
permit the integrated delivery of behavioral
health and primary care of specialty medical
services to individuals with co-occurring mental illnesses and chronic medical or surgical diseases at a single service site.
• Requires a grant recipient to agree to make
available nonfederal contributions matching
federal funds provided.
MHLG Supporting Letter(s) Excerpts
This legislation is vital to the health and well being of people with mental illness, as evidenced in
a 2006 report developed by the Medical Directors
Council of the National Association of State Mental
Health Program Directors (NASMHPD). Their report found that people with mental illnesses seem to
have the shortest life expectancy and the highest levels of disability among any other subgroup in all of
American public health. For this reason, we are particularly pleased with the inclusion of provisions that
would co-locate primary care, specialty medical care,
and substance use treatment services in Community
Mental Health Organizations throughout the United
States. In addition, your legislation would appropriate
much-needed funding to support the construction
or modernization of facilities used to provide mental
health and behavioral health services.
(800) 592-1125
Since the President’s New Freedom Commission
Report referred to a “workforce crisis” in the mental
health and substance abuse field, we also support
the personnel preparation initiatives contained in
these bills. Both the new university-based training
programs as well as additional student loan assistance will help community mental health programs
operating in health professional shortage areas. In
addition, the new tele-mental health and health information technology programs contained in your
legislation will help address the twin goals of improving the quality of care and expanding access to
behavioral health services in rural areas.
H.R. 6375 and S. 3195 Healthy
Transition Act of 2008
This bill is in the first step in the legislative process.
Introduced bills go first to committees that deliberate,
investigate, and revise them before they go to general
debate. The majority of bills never make it out of committee. Keep in mind that sometimes the text of one
bill is incorporated into another bill, and in those cases
the original bill, as it would appear here, would seem
to be abandoned. [Last Updated: Sept. 27, 2008]
Healthy Transition Act of 2008—Amends the
Public Health Service Act to require the Secretary of
Health and Human Services to award grants or cooperative agreements to states: (1) to develop plans
for the statewide coordination of services to assist
adolescents and young adults with serious mental
health disorders in acquiring the skills, knowledge,
and resources necessary to ensure their healthy transition to successful adult roles and responsibilities;
and (2) for the coordination of such services.
• Requires the Secretary to designate a federal
entity, or establish a Committee of Federal
Partners, to coordinate programs providing
such services.
• Directs such entity or committee to: (1) review
how federal programs and efforts that address
issues related to the transition of adolescents
and young adults with serious mental health
disorders may be coordinated to ensure the
maximum benefit for the individuals being
served; and (2) provide technical assistance to
the states who are planning or implementing
programs under this Act.
Excerpts from MHLG supporting
letter(s) for The Healthy Transitions
Act, H.R. 6375/S. 3195
According to the Government Accountability Office,
an estimated 2.4 million youth within transition
ages (18 to 26) have serious mental health disorders.
Although this population is not unique in experiencing difficulties as they transition to adulthood, they
are more likely than their peers to experience poor
ADDITIONAL INFO
The law:
requires
• Generally
parity of mental health
benefits with medical/
surgical benefits with
respect to the application of aggregate lifetime and annual dollar
limits under a group
health plan
• Provides that employers retain discretion
regarding the extent
and scope of mental
health benefits offered
to workers and their
families (including cost
sharing, limits on numbers of visits or days
of coverage, and requirements relating to
medical necessity)
The law also contains the
following two exemptions:
Small employer exemption—MHPA does not
apply to any group health
plan or coverage of any
employer who employed
an average of between 2
and 50 employees on business days during the preceding calendar year, and
who employs at least 2 employees on the first day of
the plan year.
Increased cost exemption—MHPA does not apply to a group health plan or
group health insurance coverage if the application of
the parity provisions results
in an increase in the cost under the plan or coverage of
at least one percent.
Fact sheet: The mental health parity act.
(2008). U.S. Department of Labor Employee Benefits Security Administration.
Retrieved November 25, 2008, from
http://www.dol.gov/ebsa/newsroom/
fsmhparity.html
outcomes, including areas of employment
and education. Left without access to necessary services and supports, successful transitions to adulthood cannot be realized. The
Healthy Transitions Act would help young
adults with serious mental health disorders
obtain vital resources, knowledge, and skills
necessary for adulthood.
The Healthy Transitions Act would establish
planning and implementation grants to states
to assist in the development of a coordinated
service delivery system to maximize continuity of care and access to services. Young adults
who are transitioning to the adult mental
health system will be able to benefit from the
infrastructure that would be developed to access such services as peer support programs,
independent living and life support skills, as
well as employment, housing, and education
supports. Additionally, H.R. 6375 [S.3195]
would establish a committee of federal partners to help coordinate the myriad of federal
programs that assist young adults with mental disorders and provide technical assistance
to states as they implement their plans.
Reauthorization of the Juvenile Justice
and Deliquency Prevention (JJDPA),
S. 3155
Juvenile Justice and Delinquency Prevention
Reauthorization Act of 2008—Amends the
Juvenile Justice and Delinquency Prevention
Act of 1974 (Act) to reauthorize through
FY2013 the juvenile delinquency prevention
programs of such Act.
• Requires the Administrator of the Office of Juvenile Justice and Delinquency Prevention (Office) to include in
the annual report of the Office information on juveniles held in state and
local secure detention and correctional
facilities, the treatment of status offenders (e.g., runaways, truants), and
evidence-based programs for juvenile
delinquency prevention.
• Expands requirements for state plans
under the Act to require: (1) statewide
compliance with the core requirement
of the Act for protection of incarcerated
juveniles; (2) alternatives to detention
for juveniles who are status or first-time
minor offenders; (3) use of community-based services to address the needs of
at-risk youth; (4) programs to improve
the recruitment, selection, training,
and retention of professionals working in juvenile delinquency prevention
programs; and (5) the identification of
racial and ethnic disparities among juveniles in the juvenile justice system.
• Authorizes the Administrator to make
incentive grants to state and local governments for juvenile delinquency prevention programs, including evidencebased programs for the prevention
and reduction of juvenile delinquency,
personnel recruitment and training,
and mental health and substance abuse
screening and treatment.
• Includes mentoring programs as a
permissible grant purpose under the
Incentive Grant Program for Local Delinquency Prevention.
• Reauthorizes such grant program through
FY2013.
Excerpts from MHLG
Letter of Support
We strongly urge you to improve and expand
upon provisions in S. 3155 that would significantly help address the shameful plight of
too many young people with mental disorders
intersecting with the juvenile justice system.
In fact, studies have shown that 70 percent
of youth in the juvenile justice system have a
diagnosable mental health disorder. Clearly,
given this alarming statistic, decreasing this
significant prevalence and appropriately reducing juvenile crime is a priority, and the
reauthorization of the Juvenile Justice and
Delinquency Prevention Act is the right opportunity to undertake this work.
We urge you to build upon S. 3155 by
including a set of mental-health-specific improvements. …
Specifically, we urge you to consider adding four provisions:
• Establish grants for partnerships between state and local juvenile justice
agencies and state and local mental
health authorities (or appropriate children service agencies) for diversion and
treatment programs
• Establish grants to provide training to
individuals involved in making decisions regarding the disposition of cases
involving youth who enter the juvenile
justice system
• Establish grants to develop comprehensive collaborative plans to address
the service needs of juveniles with mental health or substance abuse disorders
who come into contact with the justice
system or who are at risk of coming
into contact with the justice system
• Establish a Protection and Advocacy
(P&A) program to monitor condi-
tions of confinement (in facilities
where youth with disabilities are incarcerated) and compliance with
the core protections of the JJDPA
Mental Health on Campus
Improvement Act (S. 3311)
Full Text: http://www.govtrack.us/congress/
billtext.xpd?bill=s110-3311
MHLG Letter of Support Excerpts
In the 2006 National College Health
Assessment, 43.8% of the 94,806 college
students surveyed reported that during the
past year they “felt so depressed it was difficult to function.” Additionally, one out of
every 11 students stated that they had “seriously considered suicide at some point during
the previous year.” Students also named depression as one of the top 10 impediments to
academic performance. Unfortunately, many
colleges and universities are ill-equipped
to address the mental health needs of their
communities. The 2007 National Survey
of Counseling Center Directors found that
the average ratio of counselors to students
on campus is nearly 1 to 2000, the recommended ratio being 1 to 1000.
To address such troubling figures, S. 3311
aims to maximize the likelihood that students
who require mental health treatment receive
it and to ensure that their problems not reach
crisis proportions before services become
available. To achieve this, the bill establishes
grants to eligible colleges and universities to
foster a comprehensive approach to campus
behavioral health issues, including promotion
of mental health; prevention of behavioral
health disorders; expanding campus mental
health services and mental health training,
education, and outreach; and developing and
disseminating best practices to other colleges
and universities.
The legislation also calls for the establishment of a national public education campaign, focusing upon mental and behavioral
health on college campuses. Such a campaign
would assist in improving the understanding
of mental health and mental disorders and
serve to encourage help-seeking behaviors.
As the new Administration and Legislative
bodies will be challenged with health-care
issues, it is imperative that we educate and
assure that mental health care will secure an
equitable position. n
ISSUES IN THERAPY
By Bruce Gross, PhD, JD, MBA, FACFEI, DABPS, DABFE, DABFM, FAPA
False Rape Allegations:
An Assault On Justice
Of the 90,427 forcible rapes reported in 2007, 40%
were cleared by arrest or “exceptional means” (FBI,
2008d) with 23,307 of those being arrests (FBI,
2008b). Clearance of a report by exceptional means
occurs when the known suspect dies before an arrest is
made, when the victim refuses to provide the information or assistance necessary to follow an investigation
through to an arrest, or when the known suspect is
being held in another jurisdiction for a different crime
and extradition is denied. In order to clear a case by
exceptional means, the officers must have an identified suspect, know where he can be found, and have
enough evidence for a legal arrest.
Degrees of “Not True”
I
n 2007, there were 255,630 incidents of rape and sexual assault
in the United States (BJS, 2008a). Of those, 90,427 were forcible
rapes (FBI, 2008c). This represents one forcible rape occurring
somewhere in the United States every 5.8 minutes (FBI, 2008a).
Persons in the age group of 12 to 19 were raped and sexually assaulted at a significantly higher rate than any other age group (Tjaden &
Thoennes, 2000; BJS, 2008b).
(800) 592-1125
A certain percentage of rape complaints are classified as “unfounded” by the police and excluded from
the FBI’s statistics. For example, in 1995, 8% of all
forcible rape cases were closed as unfounded, as were
15% in 1996 (Greenfeld, 1997). According to the
FBI, a report should only be considered unfounded
when investigation revealed that the elements of the
crime were not met or the report was “false” (which
is not defined) (FBI, 2007).
This statistic is almost meaningless, as many of
the jurisdictions from which the FBI collects data
on crime use different definitions of, or criteria for,
“unfounded.” That is, a report of rape might be classified as unfounded (rather than as forcible rape) if
the alleged victim did not try to fight off the suspect, if the alleged perpetrator did not use physical
force or a weapon of some sort, if the alleged victim
did not sustain any physical injuries, or if the alleged victim and the accused had a prior sexual relationship. Similarly, a report might be deemed unfounded if there is no physical evidence or too many
inconsistencies between the accuser’s statement and
what evidence does exist. As such, although some
unfounded cases of rape may be false or fabricated,
not all unfounded cases are false.
The term “unfounded” is not a homogeneous
classification and, to date, there is not a formalized, accepted definition of “false rape allegations.”
Certainly, the designation of false accusation should
not include those situations in which the accuser
was raped but unintentionally identified the wrong
person as the alleged perpetrator. The definition of
false allegation of rape cannot be limited to the situation in which the victim recants the accusation.
There are women who were truly raped but for any
number of reasons choose to recant. On the other
ADDITIONAL INFO
There are several online
resources devoted to increasing awareness of the
fact that false rape accusations are an all-too-common reality. The moderators of these information
sites provide a wealth of
articles, links, and statistics on false rape charges. One Web site is www.
falserape.net.
Falserape.net provides
news briefs on publicized
cases of false rape, links
to other in-depth articles,
and a list of helpful books
on the subject. An additional section addressing legal issues is also
available.
The Web site states that
it was created by a concerned mother to increase
awareness that women
sometimes make false
rape charges and destroy the lives and reputations of innocent men,
while the false accusers
face no repercussions.
For more information,
please visit www.falserape.net.
hand, there are women who were not raped but do
not recant their accusation.
Perhaps the designation of false allegation might
best be used exclusively for those cases in which it is
determined that the accuser intentionally fabricated
the allegation of rape. That is, the accuser claims an
incident of forced sexual contact took place when no
such incident occurred, or the contact that did occur
was consensual. In addition, this would include cases
in which a rape was committed, but the victim knowingly identified the wrong person as the perpetrator.
Just as there continues to be strong resistance
to the fact that some children (for a variety of reasons) lie about having been sexually molested or
assaulted, the judicial system, mental health practitioners, and the public at large are reticent to accept that some women (and men) lie about having
been raped. However, there is ample evidence that
adults lie about virtually anything, including grave
matters that have serious consequences for others.
Crying Rape
Although there is no doubt that false rape allegations
occur, it is extremely difficult to determine what percentage of rape reports is intentionally false. This is
due to many factors, including jurisdictional variation in definition, criteria, and reporting practices,
The researchers further investigated those cases
that the police, through their investigation, had ultimately determined were “false” or fabricated. During
the follow-up investigation, the complainants held
fast to their assertion that their rape allegation had
been true, despite being told they would face penalties for filing a false report. As a result, 41% of all
of the forcible rape complaints were found to be
false. To further this study, a similar analysis was
conducted on all of the forcible rape complaints
filed at two large midwestern public universities
over a 3-year period. Here, where polygraphs were
not offered as part of the investigatory procedure, it
was found that 50% of the complaints were false.
Charles P. McDowell, a researcher in the United
States Air Force Special Studies Division, studied
the 1,218 reports of rape that were made between
1980 and 1984 on Air Force bases throughout the
world (McDowell, 1985). Of those, 460 were found
to be “proven” allegations either because the “overwhelming preponderance of the evidence” strongly
supported the allegation or because there was a conviction in the case. Another 212 of the total reports
were found to be “disproved” as the alleged victim
convincingly admitted the complaint was a “hoax”
at some point during the initial investigation. The
researchers then investigated the 546 remaining or
“THERE IS AMPLE EVIDENCE THAT ADULTS LIE ABOUT VIRTUALLY ANYTHING,
INCLUDING GRAVE MATTERS THAT HAVE SERIOUS CONSEQUENCES...”
as well as the fact that not all rapes are reported.
Although the FBI had set 8% as the average rate of
false (actually, unfounded) accusations during the
late 1990s, there is remarkable variation in the estimates of false allegations of rape found in the literature (Kanin, 1994; Epstein, 2005). A review of
those studies on false rape accusations conducted
between 1968 and 2005 showed a percentage range
from 1–90% (Rumney, 2006).
Very little formal research has been conducted
on the prevalence of false allegations of rape. One
study looked at the 109 cases of forcible rape that
were disposed of in one small midwestern town
between 1978 and 1987 (Kanin, 1994). The given
town was specifically selected for study because the
police department used a uniquely objective and
thorough protocol when investigating rape complaints. Among other procedural safeguards, officers did not have the discretion to drop rape investigations if they concluded the complaint was
“suspect” or unfounded. Every rape accusation had
to be thoroughly investigated and included offering
a polygraph to both the accuser and the accused.
Cases were only determined to be false if and when
the accuser admitted that no rape occurred.
“unresolved” rape allegations including having the
accusers submit to a polygraph. Twenty-seven percent (27%) of these complainants admitted they
had fabricated their accusation just before taking
the polygraph or right after they failed the test. (It
should be noted that whenever there was any doubt,
the unresolved case was re-classified as a “proven”
rape.) Combining this 27% with the initial 212 “disproved” cases, it was determined that approximately
45% of the total rape allegations were false.
Unfortunately, like the two studies presented
here, the empirical studies that exist on the frequency of false rape allegations are sparse in number and have notable limitations. Small sample sizes
and non-representative samples preclude generalizability. Regardless, the mere number of publicized
incidents of false accusations of rape over the last
two decades indicates not only a need for further
investigation into the problem, but a better understanding of how to identify such cases.
The Truth Behind the Lie
As with all of human behavior, there are numerous
reasons why a person would lie about being raped.
In the study of false rape allegations in the midwww.americanpsychotherapy.com
western town and state universities, over half of the
accusers fabricated the rape to serve as a “cover story” or alibi. This included 56% of the non-student
and 53% of the student false accusers. The most
frequent context and motive for the fabricated rape
was consensual sex with an acquaintance that led to
some sort of problem for the accuser. The perceived
problem was typically something that caused feelings of shame and guilt in the accuser (such as contracting a sexually transmitted disease or becoming
pregnant), which was bound to be discovered and
received negatively by family or friends.
Approximately half of the accusers who were motivated by a need for an alibi identified the alleged
rapist. Their goal was not to harm or cause problems
for the acquaintance, but to protect themselves in
what they perceived to be a desperate situation. As
with most lies, the false rape accusation allowed the
accuser to deny responsibility by creating an alternate reality into which to escape.
The next most common reason for lying about
being a victim of rape was revenge, rage, or retribution. In the Midwest study, this included 27% of
the non-student and 44% of the student accusers.
In these cases, the false victim had suffered some
real or perceived wrong, rejection, or betrayal by
the alleged rapist. As the purpose of making the accusation was to obtain some measure of revenge,
the “suspect” was always identified. Researchers in
the Air Force study also found that spite or revenge
and the need to compensate for a sense of personal
failure through an alibi accusation were the primary
motives for false rape reports.
There are a range of other reasons why women
made false allegations of rape. For some, it was to
meet the overwhelming need for attention often associated with Munchaussen Syndrome or Borderline
Personality Disorder. In those cases a specific suspect
was seldom identified. Others filed false reports in
an attempt to essentially “extort” money from the
accused, who was typically wealthy. Because the goal
was financial, the accuser was typically not motivated to pursue the case through formal legal channels,
preferring to push for a settlement.
As with certain false allegations of child sexual
abuse, false allegations of rape may be the unfortunate byproduct of “recovered memory therapy.” False
allegations (of child abuse and domestic violence, as
well as rape) are also known to arise in the context
of divorce and disputed child custody. Within the
context of the military, false reports of rape may be
filed in order to avoid deployment to war zones.
Telling a Lie from a Truth
McDowell’s research into the prevalence of false rape
allegations provided some direction for the difficult
responsibility of differentiating between a potentially
true and a possibly false report of rape. McDowell
compared the initial rape accusations made by “prov(800) 592-1125
A Selection of McDowell’s Indicators of False
Rape Allegations:
Physical injuries of false accusers usually are limited to superficial
cuts, scratches, and abrasions. Scratches often appear in a
hatching or crosshatching pattern, due to repeated attempts to
make the scratches visible. Scratches that resemble letters or
words sometimes are found on false accusers, typically on their
abdomens, but are not found on actual victims.
False accusers frequently claim that they offered vigorous and
continuing physical resistance but suffered no serious reprisals.
Most actual rape victims do not offer vigorous resistance, and
those who do often suffer extremely brutal reprisals.
A false accusation typically solves some perceived problem for
the “victim.” It may explain a pregnancy or venereal disease, or
it may exact revenge. In contrast, actual rapes seldom appear to
solve a problem. They usually create serious problems.
False accusers usually do not make their allegations initially to
authorities. Typically they make them to friends or relatives who in
turn inform the authorities.
False victims, more often than actual ones, claim to have been
raped by strangers.
False accusers, much more often that actual ones, claim to
have been attacked by multiple assailants who fit an unsavory
stereotype.
False accusers typically claim to have been victims of simple
penile insertions, or blitz rapes, without collateral sexual activity.
False accusers tend to be vague on the details, but when a false
victim does provide details she tends to do so with a relish that
actual victims seldom have.
False accusers, far more frequently than actual victims, cannot say
exactly where the rape occurred.
In false accusation cases, far more frequently than in actual cases,
the purported crime scene and the physical evidence are found to
be inconsistent with the allegation.
False accusers, more often than actual victims, claim to have
received phone calls from their “rapists” before or after the crime.
False accusers, more often than actual victims, have personal
problems, including difficulty in interpersonal relationships and a
history of lying and exaggeration.
[Source: (1985). Chicago Lawyer ]
“APPROXIMATELY
50% OF THE WOMEN
WHO FILED FALSE
REPORTS CLAIMED
THEIR ASSAILANT
WAS A STRANGER
OR SOMEONE THEY
KNEW INDIRECTLY
(BUT WHOSE NAME
SHE NEVER KNEW OR
COULDN’T REMEMBER).”
en” victims with those made by “disproved” complainants. His analysis revealed a number of notable
differences between the two groups. That is, there
were certain characteristics or indicators that were
found with greater frequency in baseless reports than
in proven reports.
For example, in terms of the initial disclosure, unlike false accusers, true victims tend to go directly to
law enforcement to file a report. False accusers are
more apt to tell family members or close friends,
who either report the rape themselves or push the
victim to do so. In discussing the alleged rape, false
accusers may be unable to provide detailed descriptions of the rape or may provide too much detail.
Although a significant number of true rape cases
include numerous sexual acts in addition to penile
penetration, those fabricating allegations of rape
tend to describe very limited and narrow sexual activity. False accusers may describe the incident with
inappropriate affect, such as pleasure or even pride.
Because they may have never actually suffered a rape,
the allegations of false accusers may be physically
improbable (if not impossible) or bizarre. Perhaps
most telling are numerous inconsistencies between
the accuser’s description of the rape and the presence or absence of physical evidence.
Approximately 50% of the women who filed
false reports claimed their assailant was a stranger
or someone they knew indirectly (but whose name
she never knew or couldn’t remember). Claiming an
unknown perpetrator makes the rape random and
perhaps more importantly, makes the case unsolvable. This, in turn, frees the false accuser from the
need to fabricate additional lies and the demands of
being confronted by the alleged assailant. Another
30% of false reporters identified their attacker as
someone they “kind of knew.” In comparison, 75%
of proven victims knew and were able to identify
their rapist.
It seems that the quality of physical injuries may
be the most significant of all indicators. According
to McDowell’s findings, the physical injuries sustained by false victims tend to be inconsistent or
“odd.” Because the injuries are self-inflicted, they
seldom involve highly sensitive parts of the body,
such as the vagina, nipples, lips, or eyes. Similarly,
the injuries of false complainants seldom involve
permanent injury or disfigurement. As the wounds
are self-inflicted, they tend to be on parts of the
body that are easily reached by the false accuser.
There may be numerous lacerations and abrasions,
all of which are comparatively minor in severity.
Unlike the true victim, false accusers may seem
comparatively indifferent or nonplussed by their
injuries.
As suggested above, for the vast majority of false
reporters, the allegation of rape solved a perceived
problem the accuser was, or anticipated, facing.
The same cannot be said for proven rape victims
as, for most, rape marks the onset of numerous,
long-term, and not easily resolved problems. None
of the factors identified by McDowell are individually or independently conclusive or diagnostic of
rape. Rather, the presence of one or more of the
criteria suggests the possibility of a false allegation
that should be carefully and sensitively investigated
and explored.
To test the efficacy of his criteria, McDowell had
three independent judges review all of the initially
“unresolved” rape reports using his criteria. This
group included the cases of those women who had
admitted their allegation was fabricated when confronted with taking a polygraph. For a case to be
classified as “unproved,” all three of the judges had
to determine a given complaint was false. After the
judges review, 65% of the cases in McDowell’s study
were found to be false.
There is no certainty that any or all of the indicators identified by McDowell will be present in rape
reports that appear to be “suspect.” When present,
however, they may serve to focus an investigation
of the charges, as well as to guide the treatment of
the alleged victim.
The Cost of the Crime
In most jurisdictions the accuser must admit that
the accusation was false before the charges against
the suspect will be dropped. Yet before the accuser decides to recant, the life of the falsely accused
may have been disrupted, if not destroyed. They
may have suffered any number of inequities, such
as being arrested and questioned; dealing with the
expense of hiring an attorney; being subjected to
time in jail; having trouble with their employer;
and fall-out with family and friends, to name just a
few. Even if the case is dropped, the reputation
of the falsely accused may be irreparably harmed,
because some people may believe the retraction
was “pressured,” and not true.
Worse yet for the accused, the case may go to trial.
Even if the falsely accused are acquitted, technically that does not mean they are innocent, only that
they could not be found guilty. Regardless of the
outcome of a criminal trial, the accuser can pursue
civil action against the accused, resulting in further
loss of resources. The worst possible outcome for
those falsely accused of rape might be conviction
and incarceration.
There is no way of knowing the number of defendants who have been convicted of rape on the
basis of a false allegation. One study found 28 cases in which the defendant had been convicted and
served an average of 7 years in prison before being exonerated by DNA evidence (Connors et al.,
1996). Of note, all 28 cases involved sexual assault
with the trials taking place in the mid- to late-1980s
when DNA was not routinely tested. According to
the Innocence Project, since 2000 there have been
156 cases of post-conviction exonerations
based on DNA testing, an untold number
of which involved sex crimes (Innocence
Project, 2008). The average time the wrongfully convicted person served prior to release
was 12 years. Regardless of the exact number, processing those who have been falsely
accused of rape is a clear waste of legal, judicial, and penal resources.
Essentially, there are no formal negative
consequences for the person who files a false
report of rape. Not only did the false allegation serve a purpose for the accusers, they
actually never have to fully admit to themselves, their family, or their friends that the
report was a lie. Although there are grounds
for bringing legal action against the accuser, it is virtually never done. Even should a
charge be filed, in most jurisdictions filing a
false report is only a misdemeanor.
When rape cases go to trial, alleged victims
are protected by “rape shield statutes.” In brief,
these statutes are designed to prevent defense
attorneys from using the accuser’s sexual history “against” her. At the same time, these rape
shield laws may suppress evidence related to
the woman’s history that is relevant to the issue before the court. In particular, they have
been used to exclude prior false accusations of
rape filed by the alleged victim.
Although courts have ruled inconsistently on this issue, there is legal foundation
for admitting prior false accusation into
evidence in criminal proceedings (Epstein,
2005). In a step toward ensuring justice,
perhaps when there is proof of prior false
reports, they should be allowed in. Before
this can happen, guidelines would need to
be established regarding the definition of a
“false rape accusation” and the criteria for
proof of prior acts. Similarly, consideration
should be given to making the filing of a
false report of rape a felony, rather than a
misdemeanor. Finally, instituting the possibility of a “not guilty and not credible”
verdict might provide some recovery for the
falsely accused and a clear warning to the
false complainant.
In the End
Although it may not be “politically correct”
to question the veracity of a women’s complaint of rape, failing to consider the accuser
may be intentionally lying effectively eradicates the presumption of innocence. This
Constitutional right is especially significant
when dealing with allegations of rape as in
most jurisdictions, sex offenses are the only
crimes that do not require corroborating ev(800) 592-1125
idence for conviction. Because there are often no witnesses and no physical evidence
(especially if the victim delays in filing a report), the case may come down to the credibility of the accused versus the credibility
of the accuser.
There is a fine line between supporting victims and protecting the rights of the accused.
Yet, considering the unique challenges of trying
and defending rape cases combined with the
potential costs to the falsely accused, being able
to assess the credibility of the alleged victim
takes on special importance. Inconsistencies in
the accuser’s complaint should be confronted
gently and respectfully, with awareness of the
fact that true victims may distort or even lie
out of embarrassment or shame.
References
Bureau of Justice Statistics (BJS). (2008a). Personal
crimes, 2006: Number of incidents and victimizations
and ratio of victimizations to incidents, by type of crime.
(Table 26). Criminal Victimization in the United States,
2006. Washington, D.C.: U.S. Department of Justice,
Office of Justice Programs, Bureau of Justice Statistics.
Retrieved from http://www.ojp.usdoj.gov/bjs/pub/pdf/
cvus/current/cv0626.pdf
Bureau of Justice Statistics (BJS). (2008b). Personal
crimes, 2006: Victimization rates for persons age 12 and
over, by gender and age of victims and type of crime.
(Table 4). Criminal Victimization in the United States,
2006. Washington, D.C.: U.S. Department of Justice,
Office of Justice Programs, Bureau of Justice Statistics.
Retrieved from http://www.ojp.usdoj.gov/bjs/pub/pdf/
cvus/current/cv0604.pdf
Connors, E., Lundregan, T., Miller, N., & McEwen,
T. (1996). Convicted by juries, exonerated by science:
Case studies in the use of DNA evidence to establish innocence after trial. (NCJ-161258). Washington, D.C.:
U.S. Department of Justice, Office of Justice Programs,
National Institute of Justice.
Epstein, J. (2005). True lies: The constitutional and
evidentiary bases for admitting prior false accusation evidence in sexual assault prosecutions. (Paper 697). Retrieved from http://www.law.bepress.com/expresso/
eps/697
Federal Bureau of Investigation (FBI). (2007). Methodology. Uniform Crime Report: Crime in the United
States, 2006. Washington, D.C.: U.S. Department of
Justice, Federal Bureau of Investigation. Retrieved from
http://www.fbi.gov/ucr/cius2006/methodology.html
Federal Bureau of Investigation (FBI). (2008a).
Crime Clock, 2007. Uniform Crime Report: Crime
in the United States, 2007. Washington, D.C.: U.S.
Department of Justice, Federal Bureau of Investigation. Retrieved from http://www.fbi.gov/ucr/cius2007/
about/crime_clock.html
Federal Bureau of Investigation (FBI). (2008b). Estimated number of arrests, U.S., 2007. (Table 29). Uniform Crime Report: Crime in the United States, 2007.
Washington, D.C.: U.S. Department of Justice, Federal
Bureau of Investigation. Retrieved from http://www.fbi.
gov/ucr/cius2007/data/table_29.html
Federal Bureau of Investigation (FBI). (2008c). Offense analysis, U.S., 2003-2007. (Table 7). Uniform
Crime Report: Crime in the United States, 2007. Washington, D.C.: U.S. Department of Justice, Federal Bureau of Investigation. Retrieved from http://www.fbi.
gov/ucr/cius2007/data/table_07.html
Federal Bureau of Investigation (FBI). (2008d). Percent of crimes cleared by arrest or exceptional means,
2007. (Clearance Figure). Uniform Crime Report: Crime
in the United States, 2007. Washington, D.C.: U.S. Department of Justice, Federal Bureau of Investigation. Retrieved from http://www.fbi.gov/ucr/cius2007/offense/
clearances/index.html#figure
Greenfeld, L. A. (1997). Sex offense and offenders: An
analysis of data on rape and sexual assault. (NCJ-163392).
Washington, D.C.: U.S. Department of Justice, Office
of Justice Programs, Bureau of Justice Statistics.
Innocence Project. (2008). Facts on post-conviction
DNA exonerations. Retrieved from http://www.innocenceproject.org/Content/351.php#
Kanin, E. J. (1994). False rape allegations. Archives
of Sexual Behavior, 23(1), 81–92.
McDowell, C. P. (1985). False allegations. Forensic
Science Digest, 11(4), 56–76.
Rumney, P. N. S. (2006). False allegations of rape.
The Cambridge Law Journal, 65(1), 128–158.
Tjaden, P., & Thoennes, N. (2000). Full report of the
prevalence, incidence, and consequences of violence against
women (research report): Findings from the National Violence Against Women survey. (NCJ 183781). Washington, D.C.: U.S. Department of Justice, Office of Justice
Programs, National Institute of Justice. n
About the Author
Bruce Gross, PhD, JD, MBA, FACFEI,
DABPS, DABFE, DABFM, is a Fellow of
the American Psychotherapy Association (APA) and is a regular columnist for
Annals of the American Psychotherapy
Association. He has been a member of
APA since 1999.
CHAIR’S CORNER
By Dan Reidenberg, PsyD, FAPA, CRS, MTAPA
Reflections on the Annual Conference
Welcome to the closing of the year. What a great
year 2008 was for the American Psychotherapy
Association. Our membership rose to more than
5,400 with four specialty/certification programs
helping us lead the way for practitioners. The annual conference was a big success, as those of you
who could make it know. We were in beautiful San
Diego with lush gardens, amazing blue skies, and sun
each day. Bill O’Hanlon, a former Advisory Board
member and special guest of APA, started the conference out with more than 100 people learning “The
Science of Happiness.” It was a fantastic presentation
that kept members captivated all day long and feeling very happy at the end of the day. Day 2 included
a host of topics such as how to take care of yourself
and avoid burnout, couples work, and health- and
wellness-related topics. Both new and old faces in the
breakout sessions learned new techniques for success.
Our former APA Chair led the new certification for
hospital psychology training, which was well received
and will become a great program for our membership. We once again held our annual Advisory Board
meeting in which we welcomed three new members.
We also discussed how to enhance the credibility and
marketing of our programs, as well as extended an
invitation to all APA members to write for the new
International Journal of Theoretical Psychiatry and
Psychotherapy (more on this in 2009).
Renewed Hope for Our
Field and Our Clients
s Bill O’Hanlon
s Daniel J. Reidenberg
Writing this article just days after the mental health
parity law passed has me filled with hope and optimism for our work and especially our clients. We
all know that regardless of the setting in which we
work, what we do is hard, and at times frustrating
and exhausting. However, the work of helping people change their lives is also rewarding and fulfilling.
I believe that being able to see success in many ways
is important, and that includes big and small steps.
Seeing parity pass is a big step, but a small one truly
in terms of how far we must go with that legislation for true equality. Having a client come to your
office and one week tell you that nothing major or
significant happened can also be a big step for them
and their treatment that we should recognize, just as
we do when they feel successful in something they
do for the first time.
How can you help your clients see their successes? What reframing, clarifying, and correcting can
you offer them that will help them see things more
positively? Here are five tips that you can use:
1. Bring up the “glass is half-empty or half-full”
analogy. Ask them how they are looking at
things in their life and help them see things as
half full.
2. Give them a homework assignment, and ask
them to make a chart of how many times in a
day they make a positive or negative statement.
Work with them on setting realistic goals to tip
the scale to more good than bad statements over
a 4-week period.
3. Have your client share with you and two others
a list of reasons to be satisfied, happy, successful,
or fulfilled.
4. Talk with your client about their family history
of seeing and celebrating success. Find out if
they are walking the same path or doing something very different between generations.
5. Take a measuring stick and chart out different
stages, events, etc. of your client’s life on the
measuring stick. Help them see how they measure how successful one was from another (i.e.,
graduation from college equaled two inches,
getting a big promotion was three inches, running a 5K was one inch, etc.).
After doing this with enough clients you see the
many areas of success they are experiencing and you
will as well. n
s Jan Hargrave
About the Author
Daniel J. Reidenberg, PsyD, FAPA, CRS,
MTAPA, is the chair of American Psychotherapy Association’s Executive Advisory Board
and has been a member since 1997. He is a
Fellow and Master Therapist of the American
Psychotherapy Association, the chair of the
Certified Relationship Specialist, CRS, Advisory Board, and executive director of Suicide
Awareness Voices of Education (SAVE) in Minneapolis, Minnesota. Contact him with your
thoughts at dreidenberg@save.org.
s APA members socializing at the opening reception
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PRACTICE MANAGEMENT
By Ronald Hixson, PhD, BCPC, MBA, LPC, LMFT, DAPA
Sticks and Stones and Other Tales
T
his childhood riddle was often used to teach us not to be afraid
of bullies or their words. No one likes to be hurt. When we are
hit by sticks or stones, we might have broken bones or other
physical injuries. This childish rebuff lacks credibility due to its
distortion of the truth. Such statements as “words will never hurt me”
are no more than a creative misrepresentation of the facts. Most adults
would agree that words do, in fact, hurt our feelings. Years later, we are
likely to remember situations where we were humiliated by a bully.
s Ronald Hixson
Feelings are more than skin deep. For most people,
it can be very hard to hold back a harsh response
when they feel insulted and disrespected. Many
such exchanges have escalated into dangerous relationships that have sent people to the hospital or
even the morgue. It should be clear that our world
has become harsher, meaner, and a more dangerous
place to live and work. One only has to look at all
the conflicts or wars being fought in our global communities at any one time. For those corporations
who specialize in weapons of destruction, conflicts
are a “cash cow,” bringing a steady revenue profit
that often leads to expansion. There is more incentive to create weapons than to destroy them. Changing Terms
As we listen to the pundits of economic astuteness, we hear terms such as “capitalism,” “entrepreneurism,” “economic cycles,” “marketplace generators,” and the “Market System.” Names come and
go, often fading with the rise of a more charming
term that has a life of its own. Words and phrases
begin as a sound bite and grow into a fad before
fading. We hear of ownership, welfare giveaway,
cost exploitation, price indexes, leverages, and insane oil speculation.
In previous generations, the words were somewhat
different: antitrust legislations, restraining the financial community to correct abuses, rationing of gas,
the Great Depression, “free enterprise,” “socialism,”
and “Marxism.” These zealous scholars of conjecture
would like us to believe that the Market System of
today creates a society that promotes individual initiatives and freedom of striking for gold or grabbing
for the gusto or the gold ring. Then there are the
well-trained intellectuals of a rich academic heredity who are managing the marketplace with ardent
confidence and dedicated energy for the “good of
the market.” To these sellers of stocks, bonds, real
estate, and futures, they are pushed by their lust for
the gain, which is their legal reward of “hard work.”
But is this cute phrase merely a sound bite that has
lost most of its value or a deliberate misrepresentation of the truth?
As we read about frequently, there are those who
abuse the system, who misrepresent their products and their actions in order to make more gold.
Unfortunately, there is no leader in Corporate
America or in government that acknowledges the
recognition that deception has an undoubtedly important role in selling to the general public or consumer.
Law enforcement and the judicial systems have
a term for acts of deception: fraud. But few members of the corporate offices serve much time in federal prison for such acts. (Enron Corporation was
an exception, and not all were prosecuted or sent
to prison.) However, the private enterprise corporations are filling the prisons and detention centers
of Corporate America while draining the tax dollars
from the government. These corporations are legal
and are formed to provide services for the government “cheaper.”
Many would refer to their services and behavior
as “economics of innocent fraud” (Galbraith, 2004).
The government agencies legally privatize their services by contracting them out to corporations such
as Halliburton (oil, trucking, and military services),
GEO (prisons and detention centers), NEC (electronics, education, etc.), Kiewit (border fence construction), and General Dynamics (military services,
intelligence, and transportation).
“EFFECTIVE COMMUNICATION
IS A BYPRODUCT OF A HEALTHY
ORGANIZATIONAL CLIMATE.
MALICE, BACK-STABBING, PUBLIC
CONFRONTATIONS, RUMORS,
AND A CLIMATE OF COMPETITION
WITHIN THE OFFICE TENDS
TO SABOTAGE A HEALTHY
COMMUNICATION CLIMATE.”
As the buyer drives the demand curve, the
economist will point to the power of the consumer. Such is the example of an innocent
fraud. Those in power will claim that the consumer has the power of choice, but the consumer’s choice may not be his/her first or even
second choice.
What really pushes the demand curve, as all
marketers will attest to, is the marketing plan
and the well-financed advertising. Political
campaign managers use this system to push the
demand curve in elections. In political campaigns, as in economics, the need for a strategy
of mass persuasion using different mechanisms
and vehicles of presentation to consumers is
vital for the sale of a concept, a product, and
a candidate. Shaping the response to market
campaigns is the same as shaping the response
to political campaigns. Sometimes these campaigns are not about selling a product or the
election of a politician. It can be about the sale
of a concept, such as the “war on drugs,” the
“war on terrorism,” the justification of invading Iraq, and the selling of health care as an
overpriced industry.
Expectations
Words do make a difference in our lives, so
it is important to be as precise as possible in
our exchanges. People can easily get confused,
misguided, and upset by words and irrational thoughts and unattainable expectations.
Every day we use so many words that we
often speak before formulating the words
that can be more effective and closer to describing the pictures we are attempting to
draw in the head of another person or to a
group. Psychotherapists learn that relation(800) 592-1125
ships grow in a trusting environment because
there is a mutually dependent attachment.
Organizations have attempted to learn from
this by spending millions to create a climate
of mutual support and trust. Effective communication is a byproduct of a healthy organizational climate. Malice, back-stabbing,
public confrontations, rumors, and a climate
of competition within the office tend to
sabotage a healthy communication climate.
Various theories of management have been
created to support such a healthy climate.
Peter Drucker (2001) wrote about management of resources (supplies, equipment,
hardware, software, vendors, personnel, etc.).
He was a strong leader who promoted the
training and health of employees more than
building up huge bank accounts and offshore
cash hideaways. Today’s leaders have public
relation experts handling their conversations
to the public and assisting them on forming
memos and policies that make the company
look good rather than using terms that employees and consumers might interpret differently, albeit more realistically.
Perception and Meanings
Words are not killers or weapons of mass
destruction; meanings are! And meanings
are in people. Meanings are created through
the perception of the beholder. Remember
when you were little and you walked outdoors and looked around? If you went back
to the same house, in the same community,
would you expect that your memory would
change if you now saw things differently?
No. You would have new memories just like
the cartoon from years ago that had a father and son standing in snow on their sidewalk. The father turned to the son and said,
“When I was your age, the snow was clear
up to my neck.” As you look at the two, the
father is now about 6 feet tall, and the little
boy looks about 4 years old and the snow is
up to his neck.
Some would argue that we never really
come into direct contact with reality because our reality is a product of the interaction between our experiences and our nervous system. When this interaction occurs,
there is another element that contributes to
our acknowledgement of “reality” or “truth.”
Motivation is what drives a thought to a behavior. Behavior is caused by a number of
things, such as our desire to change a feeling, a behavior in someone else, or to make
more money. Behavior is directed by our pri-
orities and is motivated by how strongly we
feel about our goals, our needs, our ideas.
When working with my patients, I try to
be conscious of what is motivating them to
keep their symptoms of pain, frustration,
fear, or/and panic. By reducing that motivation and replacing it with a new energy for a
new direction or behavior, we take the wind
out of their anger, their fears, and suggest
new courses or pathways that can help them
reach their goals.
Conflict normally doesn’t just walk up
to you and slap you in the face. Though it
can happen like that, normally it creeps up.
There is usually time to see it coming and
to make a conscious decision to move out
of the way. What might interfere with your
decision might be a problem with encoding.
If we live in isolation, we miss opportunities that are available to others who seek out
group work, are living in a larger community, attending church, are being active in the
school’s PTA, or are joining a local community service agency. The more experiences we
have, the more prepared we are for a situation
that might present itself at a most unexpected
moment.
References
Drucker, P. F. (2001). The essential Drucker. New
York: Harper Collins Publishers.
Galbraith, J. K. (2004). The economics of innocent
fraud: Truth for our time. New York: Houghton Mifflin
Company. n
About the Author
Ronald Hixson, PhD, BCPC, MBA,
LPC, LMFT, DAPA, has been a therapist for more than 25 years. He has
a Texas corporation private practice
and has founded a non-profit group
mental health organization where
he serves as President/Executive Director. He has a PhD in Health Administration from Kennedy-Western
University, an MBA from Webster
University, and graduate degrees
from the University of Northern Colorado and the University of California (Sacramento).
Book Reviews
Eleven Blunders that Cripple Psychotherapy in America
by Nicholas A. Cummings and William T. O’Donohue
s Eleven Blunders that Cripple
Psychotherapy in America
s Who Could We Ask?
Submit your book for review today! Please send
a print copy of the book,
a press release, and an
electronic photo of yourself to Editor, Annals of the
American Psychotherapy
Association, 2750 E.
Sunshine, Springfield,
MO 65804.
Photos may be e-mailed
to editor@americanpsychotherapy.com.
I insist that if you are going to refer to yourself as a
psychologist or a psychotherapist that you read this
book. No—absorb it. I know that’s a strong statement, but in this case I truly believe this book must
be read by all serious practitioners. To know where
we are going in uncertain times, one must understand from where we came. Nick Cummings, skillfully with the able assistance of William O’Donohue,
outlines more than just a simple history of the blunders that we have committed in the maturation of
psychology. Together they paint a rich history of the
mistakes we made in the process of going down the
wrong roads. Sure, it’s easy to point out the mistakes
that we have made, but more than that, they point
out the corrections that need to be implemented to
preserve psychology and psychotherapy as professions in the 21st century.
Dr. Cummings has been predicting the correct
roads for psychology and psychotherapists since
1948. He has fought to make our profession successful. He predicted the correct road and fought
against the blunders the profession has made and
continues to make. He has been a prognosticator,
a warrior, a guide, and sometimes a spiritual leader
for psychology. For 60 years, he has been leading
the way for psychology with clear visions. Much
of organized psychology has chosen at times not
to heed his warnings, and we have in turn paid for
that short-sightedness.
He fought for licensing before organized psychology
would accept it; he battled to include us in Medicare.
He taught us about HMOs and built them successfully. While he was creating and offering psychology
his gifts, organized psychology was turning him down
and digging the deep hole in which we stand today,
surrounded by quicksand.
He reminds us of such salient issues as business
is not inherently evil. We should be wooing insurance companies, not suing insurance companies.
He reminds us that we have never agreed upon core
goals and curricula in the education of our doctoral students. We fight organized medicine and the
health-care industry when we should be an integral
part of the health-care system, bringing our skills
and unique talents to collaboration and integration
with the system.
We seem to have worked so hard to deny our
involvement with the health-care system; no wonder we have been left out. We are a public relations
disaster. We don’t sell ourselves to the public. We
don’t stand up and apologize when we have been
wrong. We have lost our credibility with the public. Cummings and O’Donohue provide powerful
examples of these blunders. More importantly, they
map out a method for our recovery.
This is a fascinating book and an incredible read of
336 pages. I promise you won’t be able to put it down.
You will laugh, and you will cry. You will be enraged.
I promise you, you will not be bored. The authors
will tantalize you with their observations of political
correctness as the enemy of science and our foolish
expenditures of energy on diversity. We use diversity
to camouflage the important issues that face psychology for which we have no answers. They discuss the
importance of embracing evidenced-based therapies,
something we must learn if we are to survive and be
taken seriously as a scientific profession. n
Who Could We Ask? The Gestalt Therapy of Michael Kriegsfeld
by Lee Kassan
Gestalt therapy focuses on conflicts between aspects of
the self and the attempt by patients to avoid responsibility for their choices and behavior. When leading Gestalt
therapist Michael Kriegsfeld died suddenly in 1992, he
left behind numerous hours of videotaped group therapy work. Through excerpts from the tapes, author Lee
Kassan provides examples of Kriegsfeld’s methods that
will be of use to every therapist regardless of his or her
field or theoretical orientation. The use of illustrations
and verbatim transcripts give a unique, in-depth look
at the foundational practice of Gestalt therapy.
Divided into five main parts, Kassan explains the
differences between the Gestalt model and the medical model that is widely used by therapists today.
Theory explains the theoretical underpinnings of
Kriegsfeld’s approach and methods; Technique describes and explains the specific strategies and techniques he used; Resistance describes his ways of deal-
ing with the many varieties of patient resistance; The
Man Himself delievers a revealing, personal portrait;
and Long Excerpts show the various techniques as they
are used in the give and take of an actual session.
Who Could We Ask? is an easy-to-understand reference and its concepts accessible to a large readership.
Taking a rare glimpse of a master therapist at work,
this informative and intimate book will change the
way every therapist thinks about and approaches
his or her patients.
Lee Kassan received his MA in psychology from
the New School for Social Research in 1978 and is
a fellow of the American Institute for Psychotherapy
and Psychoanalysis. He is a licensed psychoanalyst, licensed mental health counselor, and certified
group psychotherapist in private practice in New
York City as well as a Diplomate of the American
Psychotherapy Association. n
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False Rape Allegations

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