Until the early 1990’s BPD was considered untreatable. People with this diagnosis often have other mental illnesses such as depression or substance abuse. Some therapists would refuse to treat those with BPD, finding them “difficult” clients with little prospect for improvement. In recent years, an effective therapy has been found in Dr. Marsha Linehan’s Dialectical Behavior Therapy. Far from being “untreatable”, many who suffer from BPD are living healthy, fulfilling lives.
Although much research has been done on the symptoms and possible contributing factors to BPD, risk factors have only become an important research topic since 2000. Findings indicate that one’s environment can contribute to the symptoms of BPD. Two of the risk factors that are being discussed are childhood attachment and parenting styles.
Do parenting styles and childhood attachment patterns contribute to the risk of developing Borderline Personality Disorder? The aim of this presentation is to show how this might be possible and to alert parents to the risks they may be able to minimize.
BPD exists in as much as 5.9% of the general population. While this figure seems small, when looking at the percentage of people with BPD in mental hospitals, the numbers are much greater. Of those diagnosed with personality disorders, 33% of outpatients and 63% of inpatients have BPD (Linehan, 1993). The prevalence of this disorder and the young age at which symptoms may appear clearly indicates the importance of research into treatment and minimizing risk.
The suicide rates for those with BPD are almost 9 times as high as those in the general population. Although physical and sexual abuse are not diagnostic criteria for BPD, a majority of those with the disorder have experienced such abuse. Note that this statistic does not include other forms of abuse such as emotional, verbal, and psychological abuse often suffered in childhood by people who develop BPD.
Research has shown that BPD is a major mental health issue. Because many people who have the disorder experience repeated hospitalizations, it is also a major financial drain. It is important to treat this disorder to lower or completely erase the need for hospital care.
The prefrontal cortex, amygdala, and hippocampus continue to develop after birth. These are involved in the development of a sense of self, emotion regulation, and empathy for others. Healthy development of these parts of the brain is strongly influenced by the relationship of a child to his/her primary caregiver. Brain development depends on learning from the behavior of others.
The areas involved have to do with the very basic formation of personality. This is where the “fight or flight” responses come from when one is in danger. When a child lives in constant fear, these areas “learn” to be over-active leading to an inability to differentiate true danger from any minor stressors. Imagine feeling like you needed to run for your life every time something negative occurs. Many with BPD experience these feelings daily.
Although here is some evidence to suggest that genetics plays a part in the development of BPD, the fact that the same parts of the brain which continue to develop after birth are abnormal in those with BPD is a good indication that environment may play a large part.
Currently, the main attachment pattern associated with BPD is a “disorganized” pattern in which a child fluctuates between clinging to his/her caregiver, and pushing away when attention is received. Adults with BPD can exhibit a similar pattern in relationships where they change from one minute to the next from being overly attached to someone and fearing abandonment to doing all they can to alienate the same individual. It is a combination of an intense desire for intimacy and an equally intense fear of intimacy linked with low or nonexistent self-esteem.
Abuse comes in many forms, and most of us have experienced abuse of some kind in our lives. In the case of BPD, abuse appears to occur repeatedly and most often at the hand of those who are trusted or are necessary to a child’s well-being. Neglect can take many forms, but the most insidious of these is failure to be responsive to a child’s needs whether they be for food and shelter or for love, protection, or validation. Inconsistent parenting is just that. Waking up every day not knowing “who” your caregiver is going to be, what the rules are, what you might be punished or rewarded for leaves a child with the question, “Who amI supposed to be today?” When a parent tries to control every aspect of a child’s life, the child fails to develop problem solving skills and always looks for someone to tell them what to do. Punishment has been shown to be ineffective in changing behaviors. Rewarding successes and encouraging changing behaviors works better in the long-run. Authoritarian parenting can be summed up in a quotation from the movie “Matilda” (DeVito, 1996) in which the child is told by different adults, “I’m big, and you’re little. I’m smart, and you’re stupid. I’m right, and you’re wrong, and there’s nothing you can do about it.” This attitude fosters a sense of helplessness and hopelessness in a child. How many times have you heard or read about a child who accuses someone of abuse, and his/her parent says, “That did NOT happen!”? How many times have you heard parents say to a child, “you shouldn’t feel that way” or “you have no reason to be unhappy”? This is invalidation. It makes a child doubt his/her own perceptions and, therefore, doubt his/her own reality.
In short, it is important to make parenting about your child and not about your preferences or your convenience, what your mother or father or society would say. Even if your child has genes that make them vulnerable to BPD or any other disorder, adjust yourself to fit your child and not the other way around. To quote Kahlil Gibran’s “On Children”,“Your children are not your children.They are the sons and daughters of Life's longing for itself.They come through you but not from you,And though they are with you yet they belong not to you.You may give them your love but not your thoughts, For they have their own thoughts.You may house their bodies but not their souls,For their souls dwell in the house of tomorrow, which you cannot visit, not even in your dreams.You may strive to be like them, but seek not to make them like you.For life goes not backward nor tarries with yesterday.You are the bows from which your childrenas living arrows are sent forth.The archer sees the mark upon the path of the infinite, and He bends you with His might that His arrows may go swift and far.Let your bending in the archer's hand be for gladness;For even as He loves the arrow that flies, so He loves also the bow that is stable.”
People with borderline personality disorder (BPD) can have difficulties with “black and white” thinking , or “splitting”. Mothers with BPD can see their children as all “good” or all “bad”. They also can have doubts about their ability to be parents. Because they may have trouble interpreting their own emotions, they tend to be poor at interpreting the emotions and cues of their children. Self-harm, suicidal and para-suicidal ideation and actions are common in BPD. Those with the disorder may also have difficulty regulating emotions such as anger, depression, or anxiety. When a mother expresses these symptoms, she may appear to her child to be inconsistent and unpredictable.
These mothers can express one, a combination, or all of these attitudes during a short time frame. To make things more confusing for the child, the mother may be nurturing and loving at times, also. In some cases, the self-orientation of the mother leads to a “role reversal” in which the child is made the care-taker for the mother.
Children of mothers with BPD may have a “disorganized” attachment to their mothers. They may alternate between clinging to the mother and pushing her away. It can be clearly seen that the effects of having a mother with untreated BPD can be serious and cause problems for a child from infancy through adulthood without intervention. Women who have been diagnosed with BPD should be made aware of the risks to their children that their disorder presents in order to engage in therapy designed to alleviate the symptoms.
Au Psy492 M7 A3 E Portf Cronk M
Undergraduate Studies ePortfolio Name Program, Year 1
Personal StatementMy quest to become a counseling psychologist began over 25 years ago when Iwas diagnosed with Major Depressive Disorder. I began to read everything Icould about mental disorders and found I had a true passion for helpingindividuals with mental illness. My formal education in psychology began 17years ago. I received an Associate’s Degree in psychology from a localcommunity college. During my attendance, I worked as a volunteer atMy questto become a counseling psychologist began over 25 years ago when I wasdiagnosed with Major Depressive Disorder. I began to read everything I couldabout mental disorders and found I had a true passion for helping individualswith mental illness. My formal education in psychology began 17 years ago. Ireceived an Associate’s Degree in psychology from a local community college.During my attendance, I worked as a volunteer at a children’s shelter. I attendedcollege when I could while working full time and raising a special-needs child.Parenting my son cemented my dedication to the field of mental health. In April,2011, I will earn my bachelor’s degree in psychology from Argosy University.Part of my undergraduate studies was done at the University of Texas at Austin,where I was able to take a counseling course in the education department. Mygrades in all psychology classes and my counseling class have been excellentthroughout my college experience. I am a member of both the AmericanPsychological Association and the National Society of Collegiate Scholars. 2
Personal Statement cont’d.Since beginning my education at Argosy University in 2009, I have been on thePresident’s list honor role twice.Currently, I plan to go to graduate school in order to obtain a master’s degree incounseling psychology. After completing my master’s and the requiredinternship, I will take state certification tests for Licensed Professional Counselorand Licensed Marriage and Family Therapist. I would like to pursue mydoctorate degree in the future. However, my main goal at this time is to becomecertified to practice counseling psychology as soon as possible.In 2009, I joined the National Alliance on Mental Illness. At that time I wrote aletter to the local president expressing an interest in volunteer opportunities. Iwas trained as a NAMI Connections support group facilitator in 2009 and begana support group in January of 2010. The group is a structured group for anyonewith a diagnosis of mental illness, and its focus is on being in and remaining inrecovery. In April of 2010, I was certified as a state facilitator trainer for NAMIConnections. In February of 2011, I was asked to sit on NAMI’s ConsumerNetworking Committee. My experience with NAMI has further enforced my beliefthat I have a calling for working with those with psychological issues. 3
Personal Statement cont’d. My strengths lie in interpersonal communication skills, empathy, honesty andreliability. Despite my own diagnosis, I was able to maintain a job with the sameemployer for 26 years. Being a clerical worker honed my written communicationskills Working with a diverse population in an international business hasimproved my interpersonal communication. Living with a diagnosis of depressionhas given me insight into a side of mental illness that many therapists neverexperience, and I feel that this is a great advantage in understanding clients. Ihave empathy for anyone dealing with life’s difficulties, and I understand theimportance of helping people help themselves. Parenting a child with impulsecontrol and communication issues has taught me new ways of communicating ina straightforward, non-confrontational manner.In my opinion, I am very well suited to the role of counseling psychologist. I havestruggled through financial and personal difficulties to obtain my education in thefield. Although it has taken me over 15 years to obtain my bachelor’s degree, Ihave persevered with the single goal of helping other in mind. I am able to bewarm and welcoming to people in my support group, and they leave with afeeling of renewed hope and empowerment. This leads me to believe I will beable to develop a therapeutic client-therapist relationship with those I counsel.My sense of humor, a firm belief in the resiliency of the human spirit, and sheerdedication will also be of great help in this area. 4
ResumeMargaret Cronk8000 Decker Lane, Apt. 1821Austin, Texas 78724(512) 465-2822 (Home)(512-997-5859) (Cell)Mags628@yahoo.comObjectiveAdmission to graduate school for Master of Arts in CounselingPersonal InformationDate of birth: 6/28/1952Place of birth: Baytown, TexasCitizenship: United StatesGender: Female 5
Resume cont’d.EducationArgosy University Online (2010-2011)Bachelor of Arts in PsychologyGPA 3.98University of Texas at Austin (1970-1972, 1999-2000)French major 1970-1972Psychology major 1999-2000Austin Community College (1992-1998)Associate of Arts in PsychologyRelated CourseworkCounseling (University of Texas Education Department) 6
Resume cont’d.MembershipsAmerican Psychological Association (2010, 2011)National Society of Collegiate Scholars (2010)National Alliance on Mental Illness (2009-2011)National Alliance on Mental Illness Consumer Networking Committee (2011)Argosy University Students Group (LinkedIn) (2011)Evolution of IT Group (LinkedIn) (2011)CertificationsNAMI Connections facilitatorNAMI Connections facilitator trainer for the State of TexasHonors and AchievementsNational Society of Collegiate Scholars (2010)Argosy University President’s Honor Roll (Spring, 2010; Summer, 2010) 7
Resume cont’d.Work ExperienceCorrespondence and Reports Assistant, Western Electric Co./AT&T Network Systems/Lucent Technologies, Inc. (1972-1998) Administrative assistant duties including clerical work, extensive computer work, setting up billing and recovery for light-guide production section.Volunteer WorkAustin Children’s Shelter (1992)NAMI Connections support group facilitator (2009-2011)NAMI Connections state facilitator trainer (2010-2011)Relevant Life ExperienceMother of special needs child (1989-2011)Panel to address mental health providers (2006)Stabilized Major Depressive Disorder and PTSD (in recovery, 1985-2011)Dialectical Behavior Therapy (2007) 8
Resume cont’d.Interests/SkillsInterpersonal communicationPsychology- family and children’s issuesClassical pianoLiteratureWriting 9
ReflectionOver the time I have spent at Argosy University, I have come to realize thatpsychology is truly the field I should be in. The concepts and theories seem tocome easily to me, and my fascination with the field has increased many-fold.My professors have been very encouraging and seem impressed with my work. Ibelieve that this all indicates that I have a calling in the field of psychology.My strengths in this area are interpersonal communication, empathy, open-mindedness, acceptance, and knowledge of counseling theory andpsychopathology. My weaknesses are in the area of research andindustrial/organizational theory. 10
Table of ContentsCognitive Abilities: Critical Thinking and Information LiteracyResearch SkillsCommunication Skills: Oral and WrittenEthics and Diversity AwarenessFoundations of PsychologyApplied PsychologyInterpersonal Effectiveness 11
Critical ThinkingBorderline Mothers: A Review of Studies of the Effects on Their Children Margaret Cronk Argosy University March 21, 2011 12
Borderline Mothers Much has been written in recent years about borderline personalitydisorder since Marsha Linehan’s development of an effective treatment in theearly 1990’s. Less has been written about the effects of living with a parent withthis disorder. This paper will address the current literature on the psychologicaleffects on children with mothers who are diagnosed with BPD. The research shows that the expression of certain BPD symptoms bymothers put their children at risk for developing psychological, behavioral, andsocial difficulties later on in life. One of these symptoms is splitting, in which themother sees the child as all ―good‖ or all ―bad‖, or visualizes her own ―bad‖parent in the child (Newman & Stevenson, 2005, p. 388). Other symptoms arefeelings of inadequacy in a parenting role or helplessness (Newman, Stevenson,Bergman, & Boyce, 2007, p. 604), as anger, fear, or despair. inability to read achild’s ―cues‖ (Crittenden & Newman, 2010, p. 434), identity confusion, self-harm or suicidal tendencies (Macfie & Swan, 2009, pp . 1004-1005), anddifficulties with regulating emotions such as anger, fear, or despair. When a mother acts upon these symptoms of her disorder, she canexpress her illness in many ways. In trying to engage with an infant, her actionsmay be particularly ―intense, inconsistent, and often self-oriented‖ (Hobson,Patrick, Hobson, Crandell, Bronfman, & Lyons-Ruth, 2009, p. 326). One study 13
Borderline Mothersshowed that, even in therapy, these mothers may feel jealous of the attentiontheir children receive, and may repeatedly bring the focus back to their ownsituations and needs (Newman & Stevenson, 2008, p. 512). Also, the mothermay practice what is called ―intrusive insensitivity‖ (Macfie & Swan, 2009, p.995) in which she continually tries to engage when the child does not want to(Hobson, Patrick, Crandell, Garcia-Perez, & Lee, 2006, p. 338). She mayrespond to the child with anxiety, negative emotions, and even anger (Newman,Stevenson, Bergman, & Boyce, 2007, p. 599). Because of her insecurities andthe stress the cause the mother, she may take on an over-controlling andpunitive authoritarian parenting style (Newman, Stevenson, Bergman, & Boyce,2007, p. 604). The research shows that these mothers can also tend to be over-protective (Barnow, Spitzer, Grabe, Kessler, & Freyberger, 2006, p. 865) overlypossessive of their children (Conroy, Marks, Schacht, Davies, & Moran, 2010, p.290). Children of mothers with borderline personality disorder have been shownto have more psychiatric disorders than children of mothers with otherpersonality disorders (Herr, Hammen, & Brennan, 2008, p. 452). In infancy, 14
Borderline Mothersthese children tend to exhibit a ―disorganized attachment‖ pattern with theirmothers (Hobson, Patrick, Hobson, Crandell, Bronfman, & Lyons-Ruth, 2009, p.328). This means that they are not securely attached to their mothers and theymay even fear her. Sometimes this leads to reluctance to engage with strangersor indiscriminate attachment to inappropriate others. Later in childhood, thechildren may exhibit aggressive (Hobson, Patrick, Hobson, Crandell, Bronfman,& Lyons-Ruth, 2009, p. 329) or defiant (Newman, Stevenson, Bergman, &Boyce, 2007, p. 604) behavior, low self-esteem (Barnow, Spitzer, Grabe,Kessler, & Freyberger, 2006, p. 865), shame (Macfie & Swan, 2009, p. 993),confusion between reality and fantasy (Macfie & Swan, 2009, p. 993), fear ofabandonment, and poor emotion regulation (Macfie & Swan, 2009, p. 1004-1005). They may also find themselves in the role of parent to their mothers(Macfie & Swan, 2009, p. 993). In adolescence, they may find themselveslacking the confidence to make friends and suffering from chronic stress fromthe relationship with their mothers (Herr, Hammen, & Brennan, 2008, p. 462).Adulthood for the children of mothers with BPD can be especially challenging.As adults, they are vulnerable to developing BPD themselves, since the disorder 15
Borderline Mothers is thought to come from a combination of genetic vulnerability plus an―unsupportive environment‖ (Macfie & Swan, 2009, p. 995). They are also morevulnerable to developing post-traumatic stress disorder (Macfie & Swan, 2009,p. 1006) or dissociative symptoms (Hobson, Patrick, Hobson, Crandell,Bronfman, & Lyons-Ruth, 2009, p. 329). Overwhelmingly, the research shows that children of mothers with BPD areat risk. Future research could be done on the question of whether these childrenare more at risk from genetic vulnerability or environment. Studies could bedone using children of mothers who were diagnosed with BPD, but hadsuccessfully completed Dialectical Behavior Therapy or another therapydesigned to treat BPD. Would the adaptations mothers made in therapy lessenthe risks to the child? If the results showed what I expect them to show, theywould stress the risks and the importance of making sure people diagnosed withBPD get the therapy they need for their own sake and that of their children. 16
Borderline Mothers ReferencesBarnow, S., Spitzer, C., Grabe, H. J., Kessler, C., & Freyberger, H. J. (2006). Individual characteristics, familial experience, and psychopathology in children of mothers with borderline personality disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 45(8), 965-972.Conroy, S., Marks, M. N., Schacht, R., Davies, H. A., & Moran, P. (2010). The impact of maternal depression and personality disorder on early infant care. Social Psychiatry and Psychiatric Epidemiology, 45(3), 285-292.Crittenden, P. M., & Newman, L. (2010). Comparing models of borderline personality disorder: Mothers experience, self-protective strategies, and dispositional representations. Clinical Child Psychology and Psychiatry, 15(3), 433-451.Herr, N. R., Hammen, C., & Brennan, P. A. (2008). Maternal borderline personality disorder symptoms and adolescent psychosocial functioning. Journal of Personality Disorders, 22(5), 451-465.Hobson, R. P., Patrick, M. P. H., Hobson, J. A., Crandell, L., Bronfman, E., & Lyons- Ruth, K. (2009). How mothers with borderline personality disorder relate to their year-old infants. The British Journal of Psychiatry, 195(4), 325-330. 17
Borderline MothersHobson, R. P., Patrick, M., Crandell, L., Garcia-Perez, R., & Lee, A. (2006). Personal relatedness and attachment in infants of mothers with borderline personality disorder. Development and Psychopathology, 17(2), 329-347.Macfie, J., & Swan, S. A. (2009). Representations of the caregiver-child relationship and of the self, and emotion regulation in the narratives of young children whose mothers have borderline personality disorder. Development and Psychopathology, 21(3), 993-1011.Newman, L. K., Stevenson, C. S., Bergman, L. R., & Boyce, P. (2007). Borderline personality disorder, mother-infant interaction and parenting perceptions: Preliminary findings. Australian and New Zealand Journal of Psychiatry, 41(7), 598-605.Newman, L., & Stevenson, C. (2005). Parenting and borderline personality disorder: Ghosts in the nursery. Clinical Child Psychology and Psychiatry, 10(3), 385-394.Newman, L., & Stevenson, C. (2008). Issues in infant-parent psychotherapy for mothers with borderline personality disorder. Clinical Child Psychology and Psychiatry, 13(4), 505-514. 18
Research SkillsComplex PTSD: Forgive or Move Forward? Argosy University Margaret Cronk March 1, 2011 19
Complex PTSDAbstract Complex PTSD is indeed a complex diagnosis encompassing years ofchildhood abuse. In many ways it is similar to borderline personality disorder.This study compares the use of forgiveness therapy and Dialectical BehaviorTherapy as a treatment for complex PTSD. The participants are 45 women whohave been diagnosed with complex PTSD and were referred by clinicians. Theywere randomly assigned in groups of 15 to either an intervention or a controlgroup. Projected results are that DBT is the more effective therapy.Literature Review At this time, post-traumatic stress disorder is a popular topic in the world ofpsychological research. It has been recognized that PTSD comes in more thanone form. The most familiar form is that suffered by war veterans. However,there is another, very insidious form of PTSD that is difficult to treat. This type iscalled ―complex PTSD‖ and results from prolonged abuse such as one wouldsuffer from being prisoner of war, or suffering chronic domestic abuse or childabuse (U.S. Department of Veterans Affairs, 2010). A leading researcher in thefield of child abuse and trauma, Bessel van der Kolk calls this condition 20
Complex PTSD―developmental trauma disorder‖ (Van der Kolk, 2005), and its symptoms closelyresemble those of borderline personality disorder. The current study focuses on victims of chronic abuse during childhood.Treatments for PTSD are numerous, and some have proven to have limitedtherapeutic effects on subjects suffering from complex PTSD. However, adefinitive treatment for complex PTSD is more problematic because of the long-standing and persistent difficulties suffered by victims of chronic childhoodabuse. This study will compare the short-term efficacy of forgiveness therapyand Dialectical Behavior Therapy for subjects with a history of chronic childabuse, with the hypothesis that DBT is the more effective of the two. ―Forgiveness is believed to be a mechanism through which individuals canexperience increases in hope and positive emotions and relief from negativeemotions, cognitions, and behaviors‖ (Lundahl, Taylor, Stevenson, & Roberts,2008, p. 465). In forgiveness therapy, the subject mentally revisits instances ofabuse, discusses how unfair the treatment was, grieves for losses caused by theabuse, and rebuilds a positive attitude toward the abuser in the interest of―finding meaning‖ in the experience (Reed & Enright, 2006, p. 921). The meta-analysis published by Lundahl et al. analyzed results from 17 studies offorgiveness therapy in which other therapeutic techniques were used as a 21
Complex PTSDsource of comparison. In all of these studies, the results showed thatforgiveness therapy was more effective for the populations studied. However,the authors stated that the results were not ―uniform‖ and appeared to be―influenced by participant characteristics and program characteristics ― (Lundahl,Taylor, Stevenson, & Roberts, 2008, p. 476). A study conducted by Reed and Enright (2006) compared forgivenesstherapy to an ―alternative therapy‖ which included practicing anger validation,assertiveness, and building interpersonal communication skills. The subjectswere women who had suffered emotional abuse from their husbands.Participants were given the Enright Forgiveness Inventory before and aftertreatment (Reed & Enright, 2006, p.922). There was more improvement inforgiveness therapy participants than in those who received alternative therapy.The conclusion was that forgiveness therapy is effective in treating women whohad suffered emotional abuse from a partner but were out of the relationship atthe time of the study. Because this type of abuse can be chronic and long-term,there is a possibility that forgiveness therapy might be effective in cases ofchronic child abuse, also. 22
Complex PTSD In contrast, Dialectical Behavior Therapy focuses on current issues anddifficulties. While not discounting past experience, there is no revisiting of thepast, grieving for losses, or trying to frame the abuser in a new light. Givingmeaning to suffering is less of an issue than just the acceptance that thesuffering happened and moving forward with new skills. These include learninghow to tolerate distress and practicing mindfulness in order to avoid mentallyreliving instances of abuse (Lynch, Chapman, Rosenthal, Kuo, & Linehan,2006). Although DBT was originally used to treat people with borderlinepersonality disorder, the techniques are being used to treat diverse disorders. Aresearch study performed in 2007 indicated that DBT was indeed useful in thetreatment of problems associated with complex PTSD (Wagner, Rizvi, &Harned, 2007, p. 399). The reasoning for performing this study was that over75% of people diagnosed with borderline personality disorder self-reportchildhood abuse (Wagner, Rizvi, & Harned, 2007, p. 392), and many of thesymptoms of borderline personality disorder are the same as those of complexPTSD. These include the inability to regulate emotions, chronic fear ofabandonment which results in distrust of others or excessive clinging to others,risk-taking behavior, and feelings of worthlessness or powerlessness (Tyrka,Wyche, Kelly, Lawrence, & Carpenter, 2009, p. 286). Because of the multiple 23
Complex PTSD facets of complex PTSD, the Wagner, Rizvi, and Harned study (2007) stated that it is not clear whether DBT is a definitive treatment for complex PTSD. Forgiveness therapy is attracting attention in certain areas, and it has shown to be effective in some populations who have suffered abuse. However, on light of the similarities between borderline personality disorder and complex PTSD, the possibility that DBT is a more effective treatment of complex PTSD than forgiveness therapy exists. Some propose that borderline personality disorder is actually a trauma disorder (Wagner, Rizvi, & Harned, 2007, p. 392), although the compilers of the DSM-IV do not recognize it as such. In comparing some of the techniques of each type of therapy, the current study is an attempt to shed light on some of the principles which might be helpful in the treatment of complex PTSD.Participants The participants of this study are 45 women who have been diagnosed with complex PTSD resulting from childhood trauma. The women are all over the age of 25 and are living away from the source of their trauma. The population was chosen from clinician referrals. Populations that have been excluded are men, those with PTSD from combat, practicing drug and alcohol addicts, those who 24
Complex PTSD have suffered trauma in adulthood only, and those suffering from other disorders which include hallucinations. Of the 45 women, 30 are Caucasian, 6 are African- American, 7 are Hispanic, and 2 are of other ethnicity. These figures were derived from percentages of the overall population of the United States (Population Reference, 2011). 39 of the women are between the ages of 25 and 64, and the remaining 6 women are over the age of 64.Instruments The Global Assessment of Functioning (GAF) (The Washington Institute) will be administered to all participants before and after intervention. The GAF is a 100 point scale which determines levels of psychological, social, and occupational functioning. It helps determine how much a person’s disorder affects functioning day to day. The Enright Forgiveness Inventory (Reed & Enright, 2006, p. 922) will be administered to participants at the beginning and end of intervention. This inventory indicates where a participant is in the process of forgiving the perpetrator of abuse. 25
Complex PTSD The PTSD Checklist (PCL) (Wagner, Rizvi, & Harned, 2007, p. 396) will be administered to all participants before intervention. The civilian form of this checklist (PCL-C) is useful in determining if PTSD actually is present, and can be used on ―any population‖ (U.S. Department of Veterans Affairs, 2010).Procedure The participants will be randomly assigned to 3 groups, each consisting of 15 participants. The control group will receive no intervention. The other two groups will participate in twice weekly group therapy sessions lasting 2 hours for a period of 6 weeks. One group will participate in forgiveness therapy, and the other group will participate in Dialectical Behavior Therapy. Both intervention groups will be led by qualified licensed therapists. Those who participate in forgiveness therapy will focus on the elements of reviewing abuse, grieving for the losses which came from the abuse, and establishing a new viewpoint of the abuser. Those who participate in DBT will focus on accepting the fact of the abuse, mindfulness exercises, and building skills to move forward. At the end of the six week period, all groups will be retested on the Enright Forgiveness Inventory and the Global Assessment of Functioning to determine the amount of progress made from the interventions. 26
Complex PTSDResults The first statistical test which will be given will be the civilian form of the PTSD Checklist (PCL-C) (Wagner, Rizvi, & Harned, 2007, p. 396). This will determine whether all participants meet the criteria for PTSD. Although they are all being treated for complex PTSD, this checklist will establish a criterion upon which their being used for the research is based. This test is a ―17-item self- report‖ (U.S. Department of Veterans Affairs, 2010) with 5 possible answers to each item. Each answer carries a score of 1-5. Therefore possible scores on this test range from 17-85. It is broken into three categories: B questions (1-5), C questions (6-12) and D questions (13-17). In order to show that the scores are significant for a diagnosis, 1 B question, 3 C questions, and 2 D questions must be rated in the category of ―moderately‖ or above (U.S. Department of Veterans Affairs, 2010). Only participants who meet this criterion will participate in the study. The second test will be the Enright Forgiveness Inventory (EFI) (Reed & Enright, 2006, p. 922). This is a 60- item self report with questions involving 6 areas of forgiveness (Reed & Enright, 2006, p. 922). Scores range from 60 to 360 with the high scores indicating ―high levels of forgiveness‖ (Reed & Enright, 2006, p. 922). This inventory will be given before and after intervention. The third test will be the Global Assessment of Functioning (GAF) ( (The Washington Institute). This is a 100 point scale with higher scores indicating higher levels of 27
Complex PTSD global functioning. This will also be administered before and after intervention. In order to determine the statistical significance of the EFI and the GAF by t-test, I would determine standard deviation from individual test scores. Then I would square these scores to find the variance. I would then divide the variance by the number of test scores minus 1 (in this case 44). Then I would add these results and take the square root of that result in order to find the value of t. For the difference in test scores to be statistically significant, they would have to exceed the value of t. To compare the two intervention groups’ scores, I would look at the difference in statistical significance on each instrument.Discussion I expect that the results of this study will show gains for both groups receiving intervention in the areas of forgiveness and global functioning. I think the group receiving the forgiveness therapy will score higher on the Enright Forgiveness Inventory (EFI) (Reed & Enright, 2006, p. 922) than the group receiving Dialectical Behavior Therapy. I would also expect the group receiving DBT to score higher on the Global Assessment of Functioning (GAF) (The Washington Institute). I think the difference in scores on the GAF will be much 28
Complex PTSDmore statistically significant than the scores on the EFI. In this case, it wouldappear that better coping skills, higher self-esteem, acceptance, andmindfulness as exemplified in DBT carry their own implications for forgivenesswithout having to review and grieve over the instances of abuse or trying to findmeaning in suffering as espoused by forgiveness therapy. There are areaswhere the two therapies overlap. However, I think that focusing on the presentand moving on with the future rather than focusing on the abuse and trying tofind meaning in it would be shown to cause better global functioning in theparticipants. Two areas which could affect internal validity that are of particular concernare hypothesis guessing (Argosy, 2011, p. 1) and attrition (Argosy, 2011, p.2).The therapies could give enough information to the participants for them to beable to answer questions in the final testing stage in a way they think isexpected rather than answering honestly. In other words, the participants mayhave guessed what gains they were expected to make from having theinterventions. This indicates that one flaw in my design is that reports of skillsdemonstrated during therapy need to be obtained from the therapists involved ingiving the interventions. With these reports, it can be shown what skills theparticipants have actually incorporated rather than those they ―think‖ they were 29
Complex PTSDexpected to learn. Attrition is a concern because both of the therapies involvepracticing tasks that participants may find unpleasant or uncomfortable. Havingto review instances of abuse may be more than some of them can handle,causing them to drop out of forgiveness therapy. Having to try to accept whathas happened to them and realize it cannot be changed or undone might be toodifficult for some of the participants in DBT to deal with. Either intervention couldhave a high attrition rate. One confounding variable might be if the participantsare still in therapy with outside therapists during the time of the experiment. Ifthis were the case, it would be impossible to determine if gains were made usingthe interventions or in the other therapy. Therefore, I should require that theparticipants not take part in any other therapy during the time of the experiment.This study could only be generalized to the female population of those withcomplex PTSD who are in therapy. This has implications for the external validityof the research. However, if the findings were significant enough, the studymight lead to research with larger, more diverse populations. If the findings were as I expected them to be, this could begin abreakthrough in the treatment of complex PTSD. Since so many of thesymptoms are the same as borderline personality disorder, Dialectical BehaviorTherapy might be the way to go in treating complex PTSD. Unlike other forms of 30
Complex PTSDPTSD, this disorder is not the result of a single trauma. Therefore, it is to beexpected that the treatment would be more intensive and lengthy in this type ofPTSD. There are several areas for future research such as whether forgivenessis really necessary in order to move past chronic abuse. Also, there might berenewed interest in determining whether borderline personality disorder isindeed a trauma-related disorder. Much of the therapy involved in treating PTSDat this time involves desensitization to triggering events through repeatedexposure. However, many people with complex PTSD have already blocked offtheir emotions to such a degree that this may not be the optimal treatment.There might also be research done on whether the techniques used inforgiveness therapy actually retard rather than aid the healing process in abusesurvivors. 31
Complex PTSD ReferencesLundahl, B. W., Taylor, M. J., Stevenson, R., & Roberts, K. D. (2008). Process-based forgiveness interventions: A meta-analytic review. Research on Social Work Practice, 18(5), 465-478.Lynch, T. R., Chapman, A. L., Rosenthal, M. Z., Kuo, J. R., & Linehan, M. M. (2006). Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62(4), 459-480.Population Reference Bureau. (2011). Population Characteristics. In Data by geography> United States> Summary (Population statistics). Retrieved from http://www.prb.org/Datafinder/Geography/Summary.aspx?region=72®ion_type=3Reed, G. L., & Enright, R. D. (2006). The effects of forgiveness therapy on depression, anxiety, and posttraumatic stress for women after spousal emotional abuse. Journal of Consulting and Clinical Psychology, 74(5), 920-929.Tyrka, A. R., Wyche, M. C., Kelly, M. M., Lawrence, H. P., & Carpenter, L. L. (2009). Childhood maltreatment and adult personality disorder symptoms: Influence of maltreatment type. Psychiatry Research, 165(3), 281-287.U.S. Department of Veterans Affairs. (2010). How does short-term trauma differ from chronic trauma? In Complex PTSD (Symptoms). Retrieved from http://www.ptsd.va.gov/professional/pages/complex-ptsd.asp 32
Complex PTSDVan der Kolk, B. A. (2005). Developmental Trauma Disorder. Psychiatric Annals, 35(5), Psychology Module, 401.Wagner, A. W., Rizvi, S. L., & Harned, M. S. (2007). Applications of dialectical behavior therapy to the treatment of complex trauma-related problems. Journal of Traumatic Stress, 20(4), 391-400.The Washington Institute. (n.d.). Global Assessment of Functioning (GAF)Scale. In On-Line Training and Assessment (Description of GAF). Retrieved from http://depts.washington.edu/washinst/Resources/CGAS/GAF%20Index.htm 33
Communication Skills: Oral and WrittenAttachment and Parenting Styles as Precursors of Borderline Personality Disorder Margaret Cronk Argosy University August 18, 2010 34
Attachment and Parenting StylesAbstract The purpose of this literature review is to provide insight into the possibleconnection between childhood attachment patterns, parenting styles, and thedevelopment of Borderline Personality Disorder in adolescence or adulthood.Included are criteria for the comparisons, physical findings, results of studies onattachment patterns, and anecdotal information concerning parenting styles.Implications of the review are that insecure attachment in infancy andauthoritarian, abusive, invalidating, or neglectful parenting can put children athigher risk for developing BPD.Introduction The unprecedented success of Marsha Linehan’s Dialectical BehaviorTherapy in treating Borderline Personality Disorder (BPD) has brought thisdisorder to the forefront of research since the early 1990’s. Once thought to bevirtually ―untreatable‖ (Gunderson, 2009), BPD is beginning to lose this label andsome of the stigma which has been attached to the disorder due to thegroundbreaking efforts of Linehan and others in the field of Cognitive/BehavioralTherapy. However, while much research has been done in the analysis of thesymptoms and possible causes of BPD, information concerning preventive 35
Attachment and Parenting Stylesmeasures for this disorder has only become prevalent since 2000. Furtherresearch into the causes of BPD needs to be addressed, and dissemination ofinformation to the general public concerning the inherent risks of dysfunctionalattachment patterns and parenting styles is vital in breaking the chain of abuseand ―poisonous pedagogy‖ (Miller, 1983/2002) which has existed forgenerations. To stress the importance of such measures, the statisticsconcerning BPD are that it exists in as much as 5.9% of the general population(Grant et al., 2009), 69%-80% of those with BPD attempt suicide or haveparasuicidal behavior and ideation ( Linehan et al., 2006), and approximately 9%succeed in committing suicide (Linehan et al., 2006). Self reports have indicatedthat up to 70% of those with BPD have been physically or sexually abusedduring childhood, and there is a comorbidity rate of 30% between BPD andPTSD ( post-traumatic stress disorder) (Gunderson, May, 2009). This paper willfocus on the role of caregiver attachment and parenting styles, including whatLinehan calls the ―invalidating environment‖(Linehan, 1993) which includestrauma and abuse, in order to show a connection between them anddevelopment of BPD in adolescence or adulthood. 36
Attachment and Parenting StylesHistory In 1978, Mary Ainsworth published her research findings on what was called ―the strange situation‖ (Ainsworth, Waters, & Wall, 1978). This study was done to assess differences in infant attachment patterns which were then put into the categories of ―securely attached‖, ―insecure avoidant‖, ―insecure resistant‖, and ―insecure disorganized‖ (Ainsworth, Waters, & Wall, 1978). Ainsworth’s assumption was that attachment patterns in infancy would affect psychological development later in life. Although there are claims that this study had some culture bias (Santrock, 2009), Ainsworth’s categories will be used for the purpose of the literature review. In his widely acclaimed work, A Secure Base: Clinical Applications of Attachment Theory (1988), John Bowlby stated, ―All of us, from the cradle to the grave, are happiest when life is organised [sic] as a series of excursions, long or short, from the secure base provided by our attachment figures.‖ The implications of his work were that secure attachments formed in childhood were the basis of life-long social competence and happiness, and that insecure attachment patterns had consequences in relationships and sense of self in adulthood (Bowlby, 1988/2005). For the purpose of this review, Bowlby’s work as well as Erik Erikson’s stages will support the importance of attachment and ―trust vs. mistrust‖ (Jenks, 2005). 37
Attachment and Parenting Styles The focus of attachment and parenting on BPD will address the following BPD symptoms: problems often seen in those with BPD: Difficulty regulating emotions Lack of a stable sense of self Feelings of emptiness Relationship difficultiesPhysical Implications One of the most persuasive issues in the argument for the connection between BPD and attachment/parenting styles is the physical evidence found through neuroimaging of the brain. This type of research has found that some structures in the brain are involved in the development of the sense of self, emotion regulation, development of empathy , and what Peter Fonagy (2007) calls mentalization which is the ability to understand or ―mentalize‖ oneself and others through behavior (Fonagy, Gergely, & Target, 2007). These structures include the anterior cingluate cortex, prefrontal cortex, superior parietal lobe, hippocampus, and amygdala. Further, affection appears to activate reward centers in the anterior hypothalamus which are important in the forming of 38
Attachment and Parenting Stylesattachments and in emotion regulation (Fonagy et al., 2007). Insecureattachment is also linked to overactivation of areas of the amygdala which haveto do with fear of losing or being able to trust a caregiver (Fonagy et al., 2007).Many of these same brain areas continue to develop after birth, and healthydevelopment depends on interaction with caregivers (Santrock, 2009). Fonagy(2007) also touched on the research showing that trauma, neglect, and lack ofstimulation can affect the expression of genes and the development of brainstructures. In 2003, a study of brain structures through neuroimaging was conductedto determine anatomical differences in the brains of female test subjectsdiagnosed with BPD from those of a control group. It was found that the womenwith BPD had a 6.2% smaller frontal lobe volume (Johnson, Hurley, Benkelfat,Herpertz, & Taber, 2003). Johnson cited a study of activity in different parts ofthe brain when the subjects were introduced to slides showing ―aversive orneutral scenes‖ (Johnson et al., 2003). In this study, there was more of anincrease in the activity of the amygdala and anterior cingulate regions of thebrain in those with BPD than in the control group. In addition, the article cited astudy in which the volumes of the hippocampus and amygdala of those withBPD had been measured, and there was a 16% decrease in the hippocampalvolume and an 8% decrease in the volume of the amygdala (Johnson et al.,2003). 39
Attachment and Parenting Styles The main implication in comparing the Fonagy and Johnson articles is that the particular areas of the brain involving emotion regulation and social bonding are the same areas in which those with BPD have abnormalities. While this may be accounted for to an extent by genetic vulnerability, the knowledge that experiences do affect the healthy development of the brain and the expression of genetic traits leads to a conclusion that experience may play as large a role in the development of BPD as does genetics.Attachment Patterns Human infants are born with certain instincts which enhance their changes of survival. Crying is one of the most important of these because it allows the infant to signal to caregivers when there is discomfort, hunger, or fear in the infant’s environment. When a caregiver is responsive to the cries of the child and supplies what is needed to comfort and insure the safety and health of the child, a bond is formed between the child and the caregiver. This is the stage which Erikson calls ―trust vs. mistrust‖ (Jenks, 2005). When there is consistent and responsive care given to the child, it is possible to develop trust in the caregiver and the environment. This produces what Ainsworth has called ―secure attachment‖ (Ainsworth, Waters, & Wall, 1978). The child learns that 40
Attachment and Parenting Styleshe/she can make an impact on the environment, which gives him/her the beliefthat the world is a safe, secure, nurturing place to live. Children with secureattachment patterns have a positive outlook on life, are more adaptable to life’schanges, and regulate emotions and behaviors well (Jorgensen, 2006).However, when caregivers are inconsistent, negligent, invalidating, or punitive inresponding to a child’s needs, secure attachment is not produced, and the childcan have problems developing a sense of his/her own self-worth and efficacy,internalizing emotion regulation learned from consistent ―attachment-figureavailability‖ (Mikulincer, Shaver, & Pereg, 2003), and is suspicious or confusedas to the probability that the environment will meet his/her needs. In order to gethis/her needs met, a child with an insecure attachment pattern develops whatMikulincer et al. (2003) describes as ―hyperactivating‖ or ―deactivating‖strategies to compensate for the lack of secure attachment. The hyperactivatingstrategy coincides with Ainsworth’s ―insecure resistant‖, or anxious attachmentin that children who use these strategies often step up behavior in order to gainthe caregiver’s attention. These behaviors include clinginess and then fightingagainst the caregiver when attention is given. Deactivating strategies coincidewith Ainsworth’s ―insecure avoidant‖ attachment in which a child avoids contactwith the caregiver due to fear of punishment or consistently frustratinginteractions with the caregiver (Mikulincer et al., 2003). In cases where there is 41
Attachment and Parenting Stylesno intervention to improve the attachment process, the survival strategiesformed in infancy and early childhood can be repeated with any potentialattachment figure over the life-span. In those who have BPD, the same sorts of insecure attachment patterns canbe seen in their adult attachments. People with BPD are ―anxious‖ in that theyconstantly fear abandonment (American Psychiatric Association, 2000), and thatthey use clinging and controlling strategies to make sure partners stay withthem. They are ―insecure resistant‖ (Ainsworth, et al., 1978) in that they fluctuatebetween thinking a potential attachment figure is perfect, or totally bad, and tendto swing between pushing people away and clinging to them. This coincides withthe DSM diagnostic criterion for BPD which says that those with BPD tend toeither ―idealize‖ or ―devalue‖ their attachment figures (American PsychiatricAssociation, 2000). Research has shown two differing opinions on the type of attachment issuespeople with BPD face. One study performed in 2004 closely linked BPD with theanxious, or ―fearful‖, attachment style (Meyer, Pilkonis, & Beevers, 2004).However, this study included only testing of responses to pictures of faces andthe subjects’ interpretation of those faces in terms of emotions. Other studieshave proposed that BPD is more closely associated with ―insecure disorganized‖(Ainsworth, Waters, & Wall, 1978) attachment (Lyddon & Sherry, 2001). Lyddon 42
Attachment and Parenting Stylesand Sherry stated that "individuals with a borderline personality style exhibit aunique, unstable, and dynamic personality structure that tends to shift amongthe various insecure attachment dimensions, creating a disorganized profile‖. Insupport of this theory, Agrawal et al. cited a study done by Karlen Lyons-Ruth inwhich a correlation was found between the ―disorganized/disoriented‖attachment styles and the ―fearful/avoidant‖ styles exhibited by adults with BPD(Agrawal, Gunderson, Holmes, & Lyons-Ruth, 2004). Regardless of the type ofinsecure attachment involved, it appears that a majority of those with BPD havehad attachment difficulties. In a study cited by Agrawal et al. (2004), 93% of testsubjects self-reported insecure attachments in childhood. There is also research to support the fact that symptoms of BPD begin inchildhood for many who suffer from the disorder. A study conducted in 2004showed that, in a sample of 9 to 19 year-olds, the prevalence of BPD was 11%(Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004). According to Lieb et al.(2004) ―research suggests that borderline personality disorder, or at least someof its symptoms, begins in the late latency period of childhood‖. This is a clearindication that certain causes of or triggers for the disorder appear in earlychildhood, leading to the conclusion that insecure attachment may be that causeor trigger. 43
Attachment and Parenting Styles Comparing the articles on attachment styles and BPD, the prevailing results seem to be that the overwhelming majority of those with BPD test and self-report as having had insecure attachments in childhood. While there are detractors of this notion who say that the correlations found were too small to be statistically significant (Levy, 2005), the majority of the literature found supports the idea that people with BPD form insecure attachments in early childhood which carry over into their adult interactions.Parenting Styles Marsha Linehan (1993) suggested that BPD is, in part, caused by what she termed the ―invalidating environment‖ in which some children grow up (Linehan, 1993). Invalidation encompasses many issues such as emotional, physical, and sexual abuse; treating the child as if his/her thoughts or feelings are unimportant or irrelevant; inconsistency in parenting; and high emotional reactivity within the home environment. Because the important qualities needed to build a strong sense of self such as ―emotional consistency and predictability, over time and similar situations‖ (Linehan, 1993) are not present, the child fails to develop the sense of self and the emotional regulation required to succeed in future 44
Attachment and Parenting Stylesinteractions. The child begins to doubt his/her own perceptions of him/herselfand of the environment. When this happens, healthy ego integrity is in jeopardy.This can lead to developing symptoms which coincide with the DSM criteria forBPD which have to do with having ―identity disturbance: markedly andpersistently unstable self-image or sense of self‖ and ―affective instability due toa marked reactivity of mood‖ (American Psychiatric Association, 2000). Peter Fonagy (2008) reported some startling evidence concerning abuseand trauma in childhood. It was found that, while trauma and abuse hadprofound impact on a child, the family’s role in mediating and dealing with thetrauma or abuse held more implications for development of BPD (Fonagy &Bateman, 2008). When the family invalidates the child’s experience of trauma orabuse by acting as if it never happened or belittling the child’s perceptions, therecan be dire consequences in the child’s sense of self and trust in his/her ownview of reality. One study cited by Fonagy and Bateman (2008) reported that84% of test subjects ―reported biparental neglect and abuse with emotionaldenial‖, or, in other words, complete disregarding of a child’s role in familyinteractions. Fonagy’s article went on to state that there were many reports ofinstances in which parents were over-involved with each other and under-involved with the child (Fonagy & Bateman, 2008). This leads to speculationabout the consequences for children of growing up in a codependentenvironment. 45
Attachment and Parenting Styles Alice Miller (1983, 2002) proposed that not only did individual parentingstyles have an effect on the continued emotional health of children, but that theparenting styles accepted by society can have an equal effect. She termedsociety’s accepted norms for parenting as ―poisonous pedagogy‖ (Miller,1983/2002). Her theory was that accepted practices which were targeted at theconvenience of the parents or the expectations of society rather than the welfareof the child could cause psychological problems throughout the life-span.Among these practices are physical punishment, which Miller considers abuse,and authoritarian parenting, in which a child is expected to obey the parentunder any circumstances. Miller drew an analogy with the accepted parentingstyle in Germany during the early part of the 20th century. Because the acceptedstyle of the day was very patriarchal and authoritarian, the Germans werebrought up being told what to do, when, and how to do it (Miller, 1983/2002).Therefore, when Hitler rose to power, he had an easy mark in that the Germanpeople were looking for a strong father figure to tell them what to do. Althoughthis analogy seems a bit extreme, if one looks at how many atrocities werecommitted because orders came from authority figures, it is certainly plausible. The implications here are that the people could not make their own decisionsand break out of the pattern in which they were raised. For a child raised in anauthoritarian, abusive environment, the consequences are conceivably thesame. The child might not be able to live autonomously without someone 46
Attachment and Parenting Stylesdetermining what he/she should do and, in effect, creating an identity forhim/her. People with BPD notoriously seek an identity through their connectionswith others, desperately seek partners, and experience feelings of emptinesswhen not in the company of those who supply an identity for them. ThomasFuchs (2007) states that, ―in fact, their personality often changes dramaticallydepending on who they are with. They seem to adopt different identities atdifferent times‖ (Fuchs, 2007). This indicates problems with individuation or theknowledge and acceptance of oneself as separate from significant others whichshould have been established in early childhood. Less than 3 generations ago, parents were admonished never to pick up ababy when it was not being fed for fear of ―spoiling‖ the child (Richards, 1974).Pamphlets on child-rearing distributed during the late 1920’s and 1930’sadvocated never kissing, hugging, or holding a child on the lap, keeping a babyon a strict feeding schedule (even waking the child to feed), and using spankingor other aversive techniques to ―train‖ a child (Richards, 1974). Many adhered tothese rules, and because people tend to parent the way they were parented,some of these practices are still in evidence today. In this manner, ―poisonouspedagogy‖ (Miller, 1983/2002) is passed from generation to generation unlessparents become aware of the damaging consequences of their parenting stylesand make a change. It is easy to see why a child raised in the ways mentionedcould have psychological problems throughout life. 47
Attachment and Parenting Styles Comparing the three sources of information above, it is evident that some parenting styles may lead to insecure attachments in early childhood. ―It is a prerequisite for the normal individuation process and development of identity that others of significance respect, recognize and validate the young persons developing individuality and identity‖ (Jorgensen, 2006). Therefore, any parenting technique which is overly controlling, punitive, neglectful, inconsistent, abusive, or discounts a child’s feelings and need for independence interferes with the healthy development of attachments and psychological functioning.Conclusion Social interaction in infancy and early childhood, especially those interactions with primary attachment figures, sets the stage for ego development, emotion regulation, and social functioning over the lifetime. When these interactions are repeatedly unhealthy or dysfunctional, a child fails to develop ego integrity, internalize a healthy model for self-care, self-soothing, emotion regulation, and effective ways of interacting with others. It has been shown that secure attachment can positively affect the developing brain and the expression and interaction of genes, while insecure attachment can interrupt or 48
Attachment and Parenting Styles―short-circuit‖ this development. More research needs to be done in order to support the idea that these elements cause or trigger BPD. This can be problematic due to the fact that longitudinal studies of children with insecure attachment cannot be performed as this would involve leaving a child in an unhealthy situation. However, it is clear that insecure attachment patterns in childhood and dysfunctional parenting can produce specific difficulties in social functioning as an adult, and that these are expressed in ways which meet some of the criteria for BPD. It is also evident that these elements can produce psychological difficulties, no matter how these are diagnosed. 49
Attachment and Parenting Styles ReferencesAgrawal, H. R., Gunderson, J., Holmes, B. M., & Lyons-Ruth, K. (2004). Attachment studies with borderline patients: A review. Harvard Review of Psychiatry, 12(2), 94-104.Ainsworth, M. D. S., Waters, E., & Wall, S. (1978). Patterns of attachment: A- psychological study of the strange situation. Hillsdale, N.J: Lawrence Erlbaum Associates, Inc.American Psychiatric Association. (2000). Borderline personality disorder. Diagnostic and statistical manual of mental disorders (IV ed.)Bowlby, J. (2005). A secure base: clinical applications of attachment theory (Rev. ed.). New York: Routledge. (Original work published 1988)Fonagy, P. & Bateman, A. (2008). The development of borderline personality disorder—A mentalizing model. Journal of Personality Disorders, 22(1), 4-21Fonagy, P., Gergely, G., & Target, M. (2007). The parent–infant dyad and the construction of the subjective self. Journal of Child Psychology and Psychiatry, 48(3/4), 288-328.Fuchs, T. (2007). Fragmented selves: Temporality and identity in borderline personality disorder. Psychopathology, 40(6), 379-387.Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., Smith, S. M., ... Ruan, W. J. (2009). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 national epidemiologic survey on alcohol and related conditions. Journal of Clinical Psychiatry, 69(4), 533-545.Gunderson, J. G. (May, 2009). Borderline personality disorder: Ontogeny of a diagnosis. The American Journal of Psychiatry, 166, 530-539. 50
Attachment and Parenting StylesJenks, C. (Ed.). (2005). Childhood: Critical concepts in sociology. New York: Routledge.Johnson, P. A., Hurley, R. A., Benkelfat, C., Herpertz, S. C., & Taber, K. H. (2003). Understanding emotion regulation in borderline personality disorder: Contributions of neuroimaging. The Journal of Neuropsychiatry and Clinical Neurosciences, 15(4), 397.Jorgensen, C. R. (2006). Disturbed sense of identity in borderline personality disorder. Journal of Personality Disorders, 20(6), 618-644.Levy, K. N. (2005). The implications of attachment theory and research for understanding borderline personality disorder. Development and Psychopathology, 17(4), 959-986.Levy, K. N., Meehan, K. B., Weber, M., Reynoso., J., & Clarkin, J. F. (2005). Attachment and borderline personality disorder: Implications for psychotherapy. Psychopathology 38 (2), 64- 74.Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M. M., & Bohus, M. (2004). Borderline personality disorder. The Lancet, 364(9432), 453-461.Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford Press.Linehan, M.M., Comtois, K.A., Murray, A.M., Brown, M.Z., Gallop, R.J., Heard, H.L., Korslund, K.E., Tutek, D.A., Reynolds, S.K., & Lindenboim, N. (2006). Two-Year randomized controlled trial and follow-up of Dialectical Behavior Therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757-766.Lyddon, W. J., & Sherry, A. (2001). Developmental personality styles: An attachment theory conceptualization of personality disorders. Journal of Counseling and Development, 79(4), 405. 51
Attachment and Parenting StylesMeyer, B., Pilkonis, P. A., & Beevers, C. G. (2004). Whats in a (neutral) face? Personality disorders, attachment styles, and the appraisal of ambiguous social cues. Journal of Personality Disorders, 18(4), 320-336.Mikulincer, M., Shaver, P. R., & Pereg, D. (2003). Attachment theory and affect regulation: The dynamics, development, and cognitive consequences of attachment related strategies. Motivation and Emotion, 27(2), 77-0102.Miller, A. (2002). For your own good: Hidden cruelty in child-rearing and the roots of violence (4th ed.). New York: Farrar, Straus, and Giroux. (Original work published 1983)Richards, M. P. M. (1974). The integration of a child into a social world. London: Cambridge University Press.Santrock, J. W. (2009). Life-Span development (12th ed.). New York: McGraw-Hill. 52
Borderline Personality Disorder Can parents minimize the risk?
Table of Contents1. Title 10. Physical findings2. Company logo 11. Brain chart3. Table of contents 12. Physical cont’d.4. Introduction 13. Attachment patterns5. Introduction cont’d. 14. Parenting styles6. Focal question 15. Conclusion7. BPD statistics 16. References8. Statistics cont’d. 17. References cont’d9. Importance of statistics 55
. Introduction Borderline Personality Disorder A serious mental illness which pervades all areas of life Once thought to be virtually “untreatable” (Gunderson, 2009) Symptoms include problems with self-esteem, emotion regulation and sustaining relationships Since the early 1990’s treatment with Dialectical Behavior Therapy has shown great promise 56
Introduction cont’d.Further research into the causes of BPD needsto be addressed, and dissemination ofinformation to the general public concerningthe inherent risks of dysfunctional attachmentpatterns and parenting styles is vital. 57
Focal question:Do parenting styles and childhoodattachment patterns contribute to therisk of developing BorderlinePersonality Disorder? 58
BPD Statistics It exists in as much as 5.9% of the general population (Grant et al., 2009) In a sample of 9 to 19 year-olds, the prevalence of BPD was 11% (Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004) 59
Statistics cont’d. 69%-80% of those with BPD attempt suicide or have parasuicidal behavior and ideation ( Linehan et al., 2006) Approximately 9% succeed in committing suicide (Linehan et al., 2006) Up to 70% of those with BPD have been physically or sexually abused during childhood (Gunderson, 2009) 60
Importance of StatisticsBecause of the prevalence of BPD, the high suiciderates involved, and the possible appearance ofsymptoms at an early age, attention needs to begiven to the risks of developing the disorder andpreventive measures that might lower those risks. 61
Literature findingsPhysical: Postnatal brain development continues into adulthood and is strongly connected with experience (Santrock, 2009). Some of the structures which continue to develop are the prefrontal cortex, the amygdala, and the hippocampus (Fonagy, Gergely, & Target, 2007). 62
Findings cont’d. Prefrontal cortex(American Health Assistance Foundation, 2010) 63
Findings cont’d. Some of the same structures are identified by neuroimaging of those with BPD as having abnormalities. 6.2% decrease in frontal lobe volume (Johnson, Hurley, Benkelfat, Herpertz, & Taber, 2003) 16% decrease in hippocampal volume (Johnson et al., 2003) 8% decrease in volume of the amygdala (Johnson et al., 2003) 64
Findings cont’d.Attachment patterns: Studies have shown a correlation between BPD and insecure attachment patterns (Meyer, Pilkonis, & Beevers, 2004) (Lyddon & Sherry, 2001). The overwhelming majority of those with BPD self-report insecure attachments in childhood. In one study, 93% of test subjects were found to have had insecure attachments (Agrawal, Gunderson, Holmes, & Lyons-Ruth, 2004). 65
Findings cont’d.Parenting styles: Parenting issues found to make a possible contribution to mental illness :AbuseNeglectInconsistencyOverly controlling, punitive, authoritarian parentingInvalidation of a child’s feelings or experiences These styles of parenting inhibit development of the sense of self, emotion regulation, and social functioning. 66
ConclusionsAlthough much research remains to be done on the effectsof attachment patterns and parenting styles on thedevelopment of BPD, it appears that these two elementscan have a strong effect in the development of mentalillness. This is a call to parents to be aware of andresponsive to the needs of a child rather than their ownconvenience or the expectations of society. 67
ReferencesAgrawal, H. R., Gunderson, J., Holmes, B. M., & Lyons-Ruth, K. (2004). Attachment studies with borderline patients: A review. Harvard Review of Psychiatry, 12(2), 94-104.American Health Assistance Foundation. (2010). Anatomy of the brain. Retrieved from http://www.ahaf.org/alzheimers/about/ understanding/anatomy-of-the-brain.htmlDeVito, D., Shamberg, M., Sher, S., & Dahl, L. (Producers), & DeVito, D. (Director). (1996). Matilda. United States: TriStar PicturesFonagy, P., Gergely, G., & Target, M. (2007). The parent–infant dyad and the construction of the subjective self. Journal of Child Psychology and Psychiatry, 48(3/4), 288-328.Gibran, K. (1996). The Prophet. Hertfordshire, England: Wordsworth Editions Limited. (Original work published 1923).Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., Smith, S. M., ... Ruan, W. J. (2009). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 national epidemiologic survey on alcohol and related conditions. Journal of Clinical Psychiatry, 69(4), 533-545.Gunderson, J. G. (May, 2009). Borderline personality disorder: Ontogeny of a diagnosis. The American Journal of Psychiatry, 166, 530-539.Johnson, P. A., Hurley, R. A., Benkelfat, C., Herpertz, S. C., & Taber, K. H. (2003). Understanding emotion regulation in borderline personality disorder: Contributions of neuroimaging. The Journal of Neuropsychiatry and Clinical Neurosciences, 15(4), 397. 68
References cont’d. Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M. M., & Bohus, M. (2004). Borderline personality disorder. The Lancet, 364(9432), 453-461. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford Press. Linehan, M.M., Comtois, K.A., Murray, A.M., Brown, M.Z., Gallop, R.J., Heard, H.L., Korslund, K.E., Tutek, D.A., Reynolds, S.K., & Lindenboim, N. (2006). Two-Year randomized controlled trial and follow-up of Dialectical Behavior Therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757-766. Lyddon, W. J., & Sherry, A. (2001). Developmental personality styles: An attachment theory conceptualization of personality disorders. Journal of Counseling and Development, 79(4), 405.Meyer, B., Pilkonis, P. A., & Beevers, C. G. (2004). Whats in a (neutral) face? Personality disorders, attachment styles, and the appraisal of ambiguous social cues. Journal of Personality Disorders, 18(4), 320-336.Santrock, J. W. (2009). Life-Span development (12th ed.). New York: McGraw-Hill. 69
Foundations of Psychology A Hypothetical Counseling SessionCounseling Theories, Module 2, Assignment 2 Margaret Cronk May 19, 2010 70
A Hypothetical Counseling Session Because I am a firm believer in Carl Rogers’ idea of ―unconditional positiveregard‖ (Seligman, 2006, p. 171), the skills I would use when meeting a newclient would display my belief in this theory. I would present myself as warm,friendly, open, concerned, and accepting of the client, no matter what his/hersituation. If I were successful in creating the mood for the therapy in this way, Ibelieve a client would be apt to return for more counseling sessions. The initial anxieties and discomforts one would experience when meeting anew client are not much different from meeting any new person. There isalways an initial concern about how the other person will perceive you andwhether you are communicating effectively with the person. However, there isalso the issue of being a ―counselor‖ who is seen as having expertise andauthority. I believe that I would try to put the client at ease by acknowledgingthat all new encounters are uncomfortable to some degree for both parties. Iwould also let the client know that I considered myself a regular person who justhappens to have training and work in this field. By acknowledging these points,I feel that the client would be more open to sharing his/her concerns with me.The most difficult part about informing a client about confidentiality would beexplaining the cases in which I would have to breach that confidentiality. Some 71
A Hypothetical Counseling Sessionpeople would see comments about being a ―risk to themselves or others‖ as anassumption that they have these problems. I would have to be very clear that Iam not assuming that they are in such a state, but I have to inform them of theirrights and my own limitations as a counselor.The main goal of therapy from a Psychoanalytic approach would be to createbalance among the id, ego, and superego (Seligman, 2006, p. 57). The egowould need to be strengthened to ―mediate‖ messages from the id and superegoin order to function successfully in life. This would be achieved through thedevelopment of healthy, mature defense mechanisms which allow the client toview and deal with life in a realistic, flexible manner (Seligman, 2006, p. 57). Inorder to do this, the therapist would initiate a relationship with the client in whichthe therapist has a certain amount of ―anonymity‖ and does not interact muchwith the client. The clinician would use transference in which a client attributesto the therapist characteristics of someone in their lives and treats the therapistas if he/she really has these attributes. Another technique is free association inwhich the client says whatever comes to mind, thus leading to uncovering deep-seated emotion. A fourth technique is abreaction in which the client recalls 72
A Hypothetical Counseling Sessionincidents and the emotions connected to them and works through thoseemotions. The therapist would then analyze and interpret information the clienthas uncovered and help the client to find better ways of dealing with issues(Seligman, 2006, pp. 58-60). The goal of Adlerian therapy would be to help a client see where their ownfaulty thought processes cause problems with behaviors and attitudes. Adler’stheory was that people caused much of their own suffering due to these faultyideas. The therapist would help the client to adjust his/her ideation to a morerealistic, functional process which would change his/her behaviors (Seligman,2006, p. 76). According to Seligman (2006), the relationship the therapist wouldbuild with the client would be one of ―shared goals, as well as mutual trust andrespect‖. This would entail much more interaction and revelation of self on thepart of the therapist than would Freudian techniques. There would be muchmore focus on the present than the past in Adlerian therapy. The therapistwould assess and analyze the client’s lifestyle, ―family constellation‖, birth order,dreams, early recollections, priorities, and behavior (Seligman, 2006, pp. 78-80).This information would then be summarized in order for the therapist to offereducation and suggestions designed to help the client ―reorient‖ their thinkingand behaviors so that they will become more healthy and functional (Seligman, 73
A Hypothetical Counseling Session2006, pp. 80-81). Finally the therapist would provide reinforcement for positivechanges a client has made and continue to provide education and insights(Seligman, p. 81). During Freudian therapy a client is likely to recover memories that had beenlong suppressed, along with the emotions connected to those memories. Thiswould provide an opportunity to explore how their perceptions and behaviorsmight have added to the distress caused by these memories. The client wouldalso have an opportunity to link his/her reactions to events in their pasts withmaladaptive ways in which he/she deals with the present. There also somecomfort in the anonymity of the therapist in this type of counseling which makesit easier for transference to occur (Seligman, 2006, p. 58). The client might feelthat he/she is indeed dealing with the people and events from the past ratherthan the therapist. I believe that Adlerian therapy can give a client a sense of empowerment.With its focus on how people’s thought processes can cause pain andmaladaptive behaviors (Seligman, 2006, p. 76) it gives hope that these thingscan be changed. The supportive, interactive relationship with the therapist cango a long way toward giving a client the feeling that it is a collaborative effortrather than something he or she needs to tackle alone. This type of therapy can 74
A Hypothetical Counseling Session help a client focus more on the present than the past, and can avoid having to relive extremely painful memories. There is a lot of encouragement used in this type of counseling which can help with building self-esteem in a client. I believe that the goals of Freudian and Adlerian therapy are basically the same. They both seem designed to produce functional, healthy, mature thought processes and behaviors in people whose histories indicate a lack of these traits. While Freud uses the idea of the balance of id, ego, and superego, the quest for mental health from the perspective of understanding emotions, thoughts and behaviors is very similar to Adler’s theories.References: Seligman, L. (2006), Theories of Counseling and Psychotherapy: Systems, Strategies, and Skills, (2nd edition), Upper Saddle River, N.J.: Pearson Education, Inc. 75
Applied PsychologyIntegration: To Mix or Match? Margaret CronkArgosy University, Counseling Theories, M8, Assessment 4 June 24, 2010 76
Integration: To Mix or Match? Although I am a strong supporter of using an integrated approach to therapy,I believe that all therapists should use Carl Rogers’ client-centered therapy(Seligman, 2009, p. 171) as a basis for setting up the initial client-therapistrelationship. I believe that empathy and unconditional positive regard(Seligman, 2009, p. 171) are the best ways to inspire trust between the clientand the therapist and to establish a feeling of ―comradeship‖ so that the clientfeels that the therapist is totally with the client in therapy and has what is best forthe client at heart at all times. My reasoning in this ties in closely with CarlRogers’ comment ―Experience is, for me, the highest authority. The touchstoneof validity is my own experience. No other person’s ideas, and none of my ownideas, are as authoritative as my experience. It is to experience that I mustreturn again and again, to discover a closer approximation to truth as it is in theprocess of becoming in me‖ (Seligman, 2009, p. 171). I have been seeing mytherapist off and on for the last 19 years. Our relationship has many facets, buthis constant unconditional positive regard and empathy has facilitated mytherapy experience in more ways than I can count. He has been, in turn,mother, father, friend, ―boss‖, peer, team member (along with my psychiatristand me), role-model, and now mentor and cheerleader in my quest to become acounselor. He has not aspired to be any of these things for himself, but hisattitude toward me has made me willing to make changes and undertake 77
Integration: To Mix or Match?challenges that I would not have dreamed of if I had not had the security andtrust in his attitude toward me. He has set the bar for the way I believe ALLpeople should be treated (not just therapy clients), and I have been able tointegrate empathy and acceptance into almost all of my interactions with others.A good, effective therapist is, in my opinion, one of the true ―lovers‖ in this world. On the other hand, I believe that no therapist should staunchly follow onetheory of therapy or one set of techniques or interventions. No two clients arethe same. There is an infinite variety of presenting conditions and situations.For a therapist to be able to help as many clients as possible, I believe he/sheshould be well-versed in a variety of theories and techniques. For example, aclient dealing with the loss of a loved one may not have cognitive distortions,dysfunctional behaviors, emotion regulation problems, or some of the otherissues addressed by the various therapies. They may simply need tounderstand the stages of grief, what stage they are in, and be giving copingmechanisms to help them get through that stage. Situational depression andMajor Depressive Disorder, while having many of the same symptoms, mightneed to be addressed differently. Deep-seated, long-term difficulties need a 78
Integration: To Mix or Match? different treatment or approach than issues that are happening in the present and are caused by environmental factors. If I came to a therapist for help with environmental stress, and he/she started trying to delve into my childhood (immediately, at any rate), I might be tempted to find another therapist! According to Seligman (2009, p. 26) the personal and professional characteristics of as successful counselor are as follows:• Characterized by strong interpersonal skills, including patience, warmth, caring, a sense of humor, and friendliness (Najavits & Weiss, 1994)• Genuine, sincere, and authentic; able to make appropriate self-disclosures, provide useful feedback, and acknowledge their mistakes and limitations• Emotionally stable, mature, and responsible• Well-adjusted and fulfilled, self-aware, with positive and realistic self-esteem, good relationships, a sense of direction, and a rewarding lifestyle• Able to acknowledge their mistakes and limitations• Capable of high levels of thinking and conceptualizing 79
Integration: To Mix or Match? • In possession of good insight into themselves and others• Aware of, sensitive to, and respectful of multicultural characteristics and differences• Engaged in and appreciative of the value of personal and professional growth and learning• Ethical, objective, and fair• Flexible and open to change and new experiences, willing to take reasonable risks• Affirming and encouraging of others• Clear and effective in both oral and written communication To this I would add that they are able to separate their own needs in the therapeutic relationship from those of their clients. The main advantage of practicing within the framework of one specific theory is that the clinician does not have to develop skills and techniques involved in other theories. He/she is able to have confidence in their knowledge of a particular theory and the techniques involved and therefore can become a sort 80
Integration: To Mix or Match?of ―expert‖ in that one theory of counseling. If a client has knowledge of theparticular theory, it might give them a sense of security to know that theirtherapist is trained and capable of using that theory. I do not see a great manyadvantages to the client in seeing this type of therapist unless they fit thestereotype a certain theory will fit. The disadvantages of this sort of practice arethat the clinician does not have a wide range of techniques and interventions,and it does not allow for much flexibility in treatment. Therefore, the number ofpeople who will be effectively treated is limited. There are obvious advantages to using an integrated approach to therapy,the main one being that ―they bring flexibility to the treatment process, enablingclinicians to tailor their work to specific clients and concerns in an effort to find agood fit between treatment and client‖ (Seligman, 2009, p. 436). Therefore, thediversity of those clients can be addressed and taken into consideration intherapy (Seligman, 2009, p. 436), and the number of clients that can besuccessfully treated can be increased. The disadvantages of an integratedapproach are that the clinician has to have expertise in a variety of treatmenttheories and techniques (Seligman, 2009, p. 435), and that it is more difficult tomake therapy coherent and relevant (Seligman, 2009, p. 435). A therapist using 81
Integration: To Mix or Match?this approach would need to be able to carefully integrate theories andtechniques and make plans for therapy concerning each particular client(Seligman, 2009, p. 435). To summarize, in my opinion, the advantages toespousing one particular theory lie more on the side of the clinician, and theadvantages to an eclectic approach lie more on the side of the client. If I were a therapist there are many techniques I would borrow from thedifferent therapeutic approaches we have studied. I see my therapeuticapproach as coming in stages. First and foremost would be Carl Rogers’ client-centered therapy in order to set up the therapeutic alliance, and this wouldcontinue throughout the therapy sessions. The second stage would beimmediate symptom relief techniques which would be behavioral in nature.Mindfulness exercises (being in the moment) which also follows Carl Rogers’goals, relaxation techniques as used in behavioral therapy, minor behaviorchanges (involving homework), and focusing on the now as used in several ofthe therapies we have studied. The reasoning behind using these strategies isthat I believe people can change behaviors more easily than cognitions, and thatthey are perhaps more willing to change behaviors. However, this might notapply in cases of addiction where I believe cognitive changes precede many 82
Integration: To Mix or Match?behavioral changes. Those cases I will leave to the angels who have morepatience and empathy than I do with addiction. I also believe that a client whosuccessfully uses behavioral techniques and feels relief from immediatesymptoms is more willing to stay in therapy and has trust that a therapist canhelp him/her. Depending on the presenting problem, behavioral techniques andchanges might be all the client needs. Therefore, the therapy would be fairlybrief. However, for those with underlying cognitive difficulties, the behavioralchanges could make changes in their belief systems and cognitions in order toopen the path for use of cognitive/behavioral therapy as espoused by Linehanand Meichenbaum (Seligman, 2009, p. 372). This would constitute the thirdstage of my approach, if needed, and would borrow elements of narrative andfamily systems therapy. An example of how I would integrate traditional cognitive/behavioral therapyand narrative therapy would be in a case where a client is having difficultyseeing more than one side of a situation. I would use reframing as used in 83
Integration: To Mix or Match? behavioral therapy (Seligman, 2009, p. 296) in the form of asking the client to imagine him/herself as another person in the situation and telling a story about their viewpoint. This might help him/her ―decenter‖ (Seligman, 2009, p. 293) and realize that there are other possible reasons, viewpoints, and elements involved in a particular situation. Realizing this might help a client change their perception of what has happened. ReferencesSeligman, L. (2009). Theories of Counseling and Psychotherapy: Systems, Strategies, and Skills (2nd ed.). Upper Saddle River, N.J: Pearson Education, Inc.Najavits, L. M., & Strupp, H. H. (1994). Differences in the effectiveness of psychodynamic 84
Ethics and Diversity AwarenessSally’s Depression Margaret CronkArgosy UniversityOctober 24, 2010 85
Sally’s Depression In responding to the psychologist’s question about Sally’s memory loss, Iwould state that, in my opinion, Sally has been dissociating from her childhoodtrauma. Dissociation can involve loss of memory and a sensation of ―lost time‖(Elzinga, Phaf, Ardon, van Dyck, 2003). This may be an attempt on Sally’s partto deny that the abuse she suffered actually occurred. Dissociation can serveas a sort of buffer against remembering traumatic events or triggers that set offmemories of the trauma. It can been observed in people with dissociativedisorders such as Dissociative Identity Disorder, but it can also be observed inpeople with PTSD (Hopper, Frewen, van der Kolk, Lanius,2007). Elzinga et al(2003) state that people who dissociate may continue to have emotionalreactions to a trauma even without being able to remember the event. Thiscould account for Sally’s anxiety. The antidepressants may not have helped Sally much because there is nounderlying neurotransmitter imbalance associated with her depression. If herdepression is purely situational, or caused by environmental factors rather thana brain abnormality, antidepressants may lift her mood a bit, but they would notchange the environmental factors of her depression or help her to deal withthem. 86
Sally’s Depression The first ethical issue I would consider in giving educational and referralservices would be client confidentiality. Protection of privacy and confidentialityare large issues in the APA code of ethics (American, 2010). Therefore anyinformation I would give a client regarding education or referrals about his/herdisorder would be done in a private session. This would also cover somediversity issues because certain ethnic or cultural groups view psychologicalservices as a source of shame or embarrassment. In referring clients to otherservices, I would be concerned with finding agencies that had experience indealing with the client’s specific ethnic and cultural needs. The referrals given toa client should be as individual as the techniques one uses in therapy. Sensitivity to diversity is essential in building a good therapist/clientrelationship. Each person is different in some way from everyone else, and atherapist needs to be able to communicate that he/she understands this andappreciates and respects those differences. This is stated in the APA code ofethics as ―In their work-related activities, psychologists do not engage in unfairdiscrimination based on age, gender, gender identity, race, ethnicity, culture,national origin, religion, sexual orientation, disability, socioeconomic status, orany basis proscribed by law‖ (American, 2010). The burden of educatinghim/herself on the culture of clients also falls to the therapist. 87