John C. McGinley kicks ass!

Ever since I saw my first episode of Scrubs it has been one of my favorite shows. I knew John C. McGinley, the actor who plays Dr. Perry Cox and is well known for his roles in Platoon and Office Space, has a son with Down Syndrome and is very active in trying to raise awareness for people with mental retardation and developmental delays. Of course, that is very cool.

I got my start working in behavioral health working with the MR/DD population as part of a program called Title XIX/Medicaid Waiver. The Waiver program, as we called it, provides an alternative to hospitalization and institutionalization by providing funding for home care workers, nurses, case managers, and psychologists to provide services for people with MR/DD diagnoses. Waiver has a number of sub-programs, such as day-habilitation (or DayHab, providing assistance to individuals in the community, which includes providing transportation, helping people shop and pay bills, etc.), residential habilitation (ResHab, providing assistance in the home with chores, personal care, cooking, etc.) and respite services, which provide parents and other unpaid caretakers with a break so that they can take care of themselves.

This is a really good program. It is also the hardest and, in some cases, least rewarding work you can do in behavioral health. Improvement comes slowly, so you can never expect to see any drastic changes from day to day or week to week, and it is physically and mentally exhausting. But I would trust a great waiver worker over just about anyone else to do the right thing when needed. This is incredible front-line training for future behavioral health workers, and I would recommend it for anyone interested in a career in the field. To put is simply, if you can work waiver, you can do anything.

But enough nostalgia. John C. McGinley was on the Bonnie Hunt Show last month and he spoke about his son and about Special Olympics, and he touched on a controversy. Apparently Dick Morris was on The O’Reilly Factor and used “the R-word,” or retard, in an interview, and a bunch of kids at the Special Olympics sent O’Reilly a letter asking for an apology. Apparently, O’Reilly did apologize, which is cool. Here’s the clip:

And here’s the clip of O’Reilly apologizing:

What does it mean, though, when he says “Dick Morris is speaking off the cuff?” Why couldn’t he just apologize? What exactly does “off the cuff” mean? Is he saying that Morris didn’t prepare a statement? That it is okay to use “retarded” as a pejorative as long as you don’t do it on national television? I mean, it’s cool that the guy apologized, but why does he have to try to backhand the apology by trying to explain away the remark? Would saying that he is speaking off the cuff and apologizing be appropriate if he had said nigger instead of retarded? Actually, the producers and O’Reilly himself would have stopped him at the time if he had dropped a racial slur, but it takes three days to apologize about using retarded as a euphemism for dumb and slandering millions of people with intellectual disabilities, people who have to work harder to do the same things we do and still end up doing as well as the average American.

Anyway, enough with the rant. John C. McGinley, I salute you!

Taking a closer look at child sexual abuse

Each year, approximately 150,000-200,000 children are sexually abused, 70-80% of those cases involve a family member or a friend of the family that the child knows, including older children. It’s an appalling proposition to anyone who wants to work in the treatment of mental disorders. The people that we are supposed to trust, the “in group,” is more likely to do damage than any stranger. Even the most well-balanced counselors and therapists I know get floored by stories of child sexual abuse.

The Journal of Mental Health Counseling published an article by Frazier et al. covering some very good information regarding recovery from CSA. Here are some of the key facts regarding recovery:

• Primary symptoms of CSA include avoidance behaviors (including caregiver phobias), developmental delays, diminished responsiveness to the outside world, lack of interest in a previously-enjoyed activity, and feelings of detachment or estrangement.
• Survivors of CSA may lose developmental achievements. They may start bedwetting behavior, or they may become unable to feed themselves.
• When an abused child views their preabuse life as high-quality, they are more likely to have a positive self-view after the abuse.
• Survivors who believe that others do not view them as responsible for the abuse often feel empowered, leading to a more positive adjustment.
• Abused children who receive emotional support from a non-offending adult are less symptomatic.

Note that the emphasis of this article is on children. Adults who survived CSA are more likely to show symptoms of depression and anxiety, but children respond well to treatment. Frazier et al. recommends using an ecosystem approach in working with child survivors of CSA, and calls for counselors to be aware of transgenerational trauma, or situations in which a child keys into an adult’s behavior surrounding the adult’s experience with sexual abuse. Children are quick to pick up cues from parents. If we can assist these children as early as possible, we may be able to break that cycle.

Of course, CSA is not without its controversies. The biggest of which is probably the diagnosis of Dissociative Identity Disorder.

I’ve been reading bits and pieces of Science and Pseudoscience in Clinical Psychology, and last night I finished a chapter on DID (Lilienfeld & Lynn, 2003). It does a great job of highlighting the controversy surrounding DID.

Briefly, DID is a disorder in which a client presents with two or more distinct “personality states” that alternate in their control over the individual. It is one of the dissociative disorders, disorders which present with disturbances with memory, identity, or perception of the external world. The common belief regarding DID is that the development of separate personalities is caused by child sexual abuse. (note: this is a more recent development. The two famous early cases, those presented in The Three Faces of Eve and Sibyl contain no mention of CSA). The belief is that the child develops the second personality as a way of protecting the primary personality from facing the fact that they are being abused.

The other camp, the place where I hang my hat, claims that DID is the result of therapist cueing. Lilienfeld & Lynn point to a few facts: that a huge number of DID cases come from only a handful of therapists, the flexibility of memory as demonstrated by Elizabeth Loftus, the fact that a majority of the cases of DID begin treatment for other problems and do not report the expression of different personalities until later.

Lilienfeld and Lynn are quick to point out that they are not denying that DID patients experience these symptoms. The question is whether the symptoms are a natural reaction to trauma.

This leads me to a story. In an earlier job, I was treating a female with DID who claimed that her parents performed ritual sexual and satanic abuse. I was an undergraduate student at the time, and I happened to read one of Loftus’ memory studies around that time, and read the FBI statements that there had never been any documented cases of ritual satanic abuse in the US. I was confused, so I went to my boss. He was (and still is) a great counselor and he said “it probably isn’t true, but it is true to her.” This, or course, is a take on the old adage with schizophrenia, never challenge the delusion. Of course, it does beg the question, how do you treat someone who bases their life on events that did not occur?

(Original Photo by D Sharon Pruitt)

Frazier, K.N., West-Olatunji, C.A., St Juste, S., Goodman, R.D. (2009). Transgenerational Trauma and Child Sexual Abuse: Reconceptualizing Cases Involving Young Survivors of CSA Journal of Mental Health Counseling, 31 (1), 22-33

Predicting Behavior: Depression in adolescent girls

It is sometimes essential that we be able to correlate behaviors that may relate to mental illness. Research points to early intervention as being an important predictor of recovery. If we can correlate one set of mental health symptoms with something that occurs early in life, and if that correlation holds true, we can better predict who will need mental health care and get services to them in a timely manner.

A recent study in the Journal of Early Adolescence points to a correlation between antisocial behavior in young girls and depression in adolescents. This is based on a University of Washington study starting with first and second graders and following them for 7 years.

Antisocial behavior is most commonly seen as a problem in boys, but this study found that antisocial behavior and anxiety were predictors of depression in early adolescence. The researchers note that more girls than boys suffer from adolescent depression.

This all leads me to question: are the minds of children and adolescents well-formed enough to apply an adult disorder to their mind. This is a serious question, I’m not doing one of those rhetorical questions to try to show that psychiatry is misguided, etc. If we were to diagnose depression in a 10-year-old girl, just as an example, on what criteria do we base this decision? Is the DSM adequate, considering the mental abilities and emotional state of a teenager?