Friday, December 12, 2014

Who's Most at Risk for Sexual Assault?

After writing my previous post, I began thinking about the hidden epidemic of sexual abuse and assault, that has been going on for hundreds or perhaps thousands of years. It's not happening on college campuses. It's happening in people's homes. The time period of life when people are at highest risk for being sexually abused or raped is before the age of 18. The most common perpetrators of sexual abuse and assault are parents.

For official statistics on child abuse, the federal government is the best source:

According to government statistics, child abuse is in decline. However, it is difficult and perhaps impossible to gain accurate statistics on child sexual abuse, because many of these cases never come to the attention of authorities.

A large percentage--although not the majority--of patients I've seen over the past 13 years in private practice were sexually abused as children. Many of them have been men. Altogether they far outnumber the patients I've seen who have been raped in adulthood.

Seemingly paradoxically, people who were sexually abused in childhood are at higher risk for being raped in adulthood, probably for a variety of reasons. They may be more likely to abuse drugs and alcohol, putting them at higher risk. They may have low self-esteem and poor self-care--rapists target such individuals. Some who were sexually abused by parents may have difficulty picking up on warning signs, because they are used to being in an environment of constant danger and/or abuse--they don't identify perpetrators as people to avoid because they are used to being in the company of similar individuals.

Society was in denial about the prevalence of child sexual abuse for a very long time. When Sigmund Freud began investigating the phenomenon of "hysteria" among women approximately 100 years ago, he came across evidence of widespread sexual abuse. He suppressed this information because he didn't think anyone would believe it and he was afraid controversy would distract from his theories about the unconscious and the development of human personality. This was a grave ethical mistake that led to disastrous trends in the field of psychoanalysis. In the early 1980s, a psychoanalytic researcher named Jeffrey Masson discovered that Freud had deliberately suppressed evidence of child sexual abuse. He wrote a book, "The Assault on Truth." Sadly, what happened next was a national panic about child sexual abuse in which many innocent people were persecuted. The most famous case involved a preschool in which it was alleged that there was an organized child sex abuse ring. After extensive investigations and prosecutions, the allegations were determined to be bogus and to have been essentially manufactured by police and prosecutors who asked young children leading questions.

 It's interesting how society has a tendency to swing between extremes of denial and panic when it comes to the issues of rape and sexual abuse.

Friday, December 5, 2014

Hard to Believe

I've been following news stories about what some have called a rape epidemic on college campuses. Most recently, I read the Rolling Stone article about the University of Virginia, and today, what seems to be a partial retraction of the story. Rolling Stone now states that the main subject of and source for the article, a young woman identified only by a first name, may not be credible.

I'm not sure how the retraction could come as a surprise to anyone who read the article. The story described how the victim was thrown on a glass coffee table that shattered, continued to lie on the shattered glass while being raped, but did not seek medical attention afterward. She left the fraternity house without anyone apparently noticing a bleeding woman with pieces of glass stuck in her back walking across campus.

From a psychological standpoint, the Rolling Stone debacle raises many interesting questions. Why would someone lie about being the victim of a crime, and why would so many people believe a story that seems suspicious? In fact, there are many psychological disorders that cause people to tell stories that aren't true. Individuals with Histrionic Personality Disorder constantly seek attention and often embellish stories to gain attention. This is considered a fairly severe disorder, but, as with many personality disorders, the individual may, to the superficial observer, appear to be totally normal. People with Borderline Personality Disorder may have delusions, and people with psychotic disorders, needless to say, have difficulty distinguishing between the real and the unreal.

There are also reasons to lie that have nothing to do with psychology, such as the desire to file a lawsuit for monetary gain, or a desire to gain attention for reasons such as publicity that could help one's career.

I think many people assume that college students' emotional disorders are generally limited to depression, anxiety disorders, substance abuse and eating disorders. But there's no reason to believe college students' mental health is any better than that of the general population. In fact, many serious  mental disorders first appear in late adolescence and early adulthood. Emotionally disturbed people are probably far more likely to attend college now than 40 years ago, because better treatments today allow them to function. People who decades ago might have spent months or even years in psychiatric facilities are now able, in some cases, to take medication or receive therapy that allow them to go to college and work.

What's even more interesting is why Rolling Stone, a major publication, violated basic rules of journalism in reporting and publishing the story. I was a journalist in my first career in the 1980s. I never would have written an extensive story about crime based on the account of one victim. My editors would have nixed such an article. I have seen interviews on TV and read other magazine articles, about campus rapes, that seem to avoid basic questions. It's interesting for me, having had two professions, to compare the way that a therapist would talk to someone who reported being raped and the way a journalist is supposed to interview that person. As a therapist, I listen to a person's story and try to understand his or her point of view. When I was a journalist, I had to assure myself of the source's credibility because the story would be distributed to tens of thousands of readers, not simply recounted to me in a private office.

The assumption that anyone who is telling a story about being victimized is telling the truth is naive at best. As a psychotherapist, I need to determine both the emotional meaning of someone's trauma and also the basic facts. Journalists should focus on the facts and let people like me do my job.

Wednesday, August 13, 2014

Run for your life

A few years ago, I came across a website apparently run by and for people with various illnesses. There were discussions, and also places where people could rate the different types of treatments for their illnesses. I went to the "depression" section to see if people gave higher ratings to medication or to psychotherapy. To my surprise, the most highly rated "treatment" for depression was exercise.

Perhaps it shouldn't be surprising. Exercise tends to make people feel better immediately, whereas medication can take weeks to work and psychotherapy may take months.

I have noticed that some of my most depressed patients don't exercise. Are they so depressed because they don't exercise, or are they not exercising because they are too depressed to be motivated to exercise? Clinicans have long noted that depression can cause vicious cycles in which the depressed person stops participating in activities that would be enjoyable and becomes more depressed as a result. Consequently, we encourage depressed patients to do the things they have enjoyed in the past, whether they feel like it or not.

 Depression can cause distorted cognitions including inaccurate memory. People with severe depression may "forget" pleasurable experiences. It's not uncommon for inaccurate memories to include memories of treatment experiences. Recently, for example, someone told me that she had taken numerous psychiatric medications in the past and none of them worked. But as she described her life and past experiences, it became clear that she had functioned much better when she had been taking anti-depressants.

There isn't a one-size-fits-all treatment for depression. Effective treatment might include a variety of modalities, some of which, such as exercise, are the sole responsibility of the patient. In my experience, most depressed people recover, if they give treatments a chance to work. 

Monday, July 28, 2014

Rules for Healthy Relationships

I agree with everything said in this blog post about relationships:

Saturday, May 31, 2014

Can anti-depressants cause violence?

I've read some commentary on the internet that Elliot Rodger, the most recent mass murderer, killed people because he was taking SSRI anti-depressants. I strongly suspect these commenters are NRA activists trying to distract from the issue of the availability of firearms. However, it is worth discussing what role, if any, psychiatric medications could play in an act of violence.

SSRIs don't cause violent acts to be committed by people whose only disorder is depression. Unfortunately, many people who receive prescriptions for SSRIs have other disorders. People with bipolar disorders (manic-depressive illness) may present to a psychiatrist with depression, and upon taking an SSRI, become manic. Mania can include symptoms of grandiosity, aggression, hostility, impulsivity, and psychosis. Needless to say, these symptoms can trigger violent acts, even homicidal acts.

Many people who have depression also have personality disorders. Narcissistic Personality Disorder and Antisocial Personality Disorder (sociopathy) have as symptoms a lack of empathy for others. People with Antisocial Personality Disorder are known for frequently breaking the law. When these individuals receive SSRIs, their depression often clears up, and they have more energy. This energy can be manifested in impulsive, sexual, aggressive or criminal behavior. It isn't necessarily mania, but an elevated mood combined with a lack of regard for others.

I read parts of Rodger's "manifesto." His thinking seemed quite grandiose through much of it and at times crossed the border into delusional. I don't believe his revenge motive; rather, I think he decided he needed an excuse for his violence in order to justify it to himself.  Rejection and bullying seemed like good justifications to him. I think that he killed people for the thrill of power and perhaps to gain notoriety. (Note that he killed men as well as women and none of the people who rejected or bullied him during childhood). He then killed himself to avoid arrest, condemnation, and jail. He knew he would never fulfill his grandiose desires, and decided that without that fulfillment, his life wasn't worth living. He wasn't going to get a blonde girlfriend who looked like a fashion model, and he wasn't interested in looking for a girlfriend who was someone more like him. This type of thinking is common among people with narcissistic problems and is the reason so many people with Narcissistic Personality Disorder present with depression. They can't fulfill their fantasies, and when reality hits, they are crushed. Rodger probably assessed his available options for achieving fame and power and came to the conclusion that mass murder was his one option.

What we need to do is keep guns out of the hands of people who are seriously emotionally disturbed regardless of whether they have been hospitalized or ruled mentally incompetent. Many severely disturbed people who are capable of extreme violence are also capable of day-to-day functioning and capable of lying to cover up their plans.

Wednesday, February 5, 2014


If one judged from stories in the media, one would think the main cause of Post-Traumatic Stress Disorder is wartime combat. In fact the most common cause of PTSD is sexual assault.

PTSD is common, and, I believe, underdiagnosed. That's because its symptoms include anxiety and what may look like depressive symptoms. Furthermore, for many years, and perhaps continuing into the present, PTSD was thought of as an illness relating to a specific trauma experienced in the recent or moderately recent past. Some psychiatrists don't look closely at the causes of symptoms and just prescribe a pill for what the symptoms look like. It may take time in therapy for a patient to reveal the complete history of the trauma(s).

Many combat veterans are apparently now receiving disability benefits for PTSD. The illness is treatable, and in my experience, most people recover. I've wondered what our society would look like if everyone who had PTSD received disability benefits and stopped working. Whole industries might grind to a halt, because childhood trauma and sexual violence throughout the life cycle, are common.  Perhaps our society doesn't take PTSD suffered by victims of childhood trauma or rape in adulthood as seriously as we take PTSD suffered by combat veterans. Of course, many combat veterans have other disorders on top of PTSD, including Traumatic Brain Injury (TBI). TBI can cause behavioral and mood disturbance and  may be misdiagnosed.

I've worked with many combat veterans as well as a large number of people who have experienced childhood trauma. In fact, the vast majority of my patients have experienced some sort of childhood trauma--it's the main reason people come to therapy. Not everyone who has experienced trauma develops PTSD, however.  Many factors can affect whether or not someone develops PTSD. I've noticed that many cases of long-term PTSD involve unresolved guilt feelings.

It can be important to distinguish acute stress symptoms from PTSD. It's normal for anyone to experience certain symptoms after experiencing a life-threatening event or witnessing a fatal or life-threatening event. These symptoms can include anxiety, flashbacks and fear of the situation or locale in which the event took place. In most cases the symptoms go away after a few weeks. If not, the individual can be diagnosed with PTSD and will need treatment.

Sunday, January 5, 2014

An Introduction to Personality Disorders

The term "personality disorder" was developed decades ago to describe patients who had a superficially normal presentation without psychosis but who, under psychoanalysis, were revealed to have deep disturbances in their psychological functioning. Many of these patients had chronic problems in interpersonal relationships or social/occupational functioning. Some had symptoms of "neurosis" such as anxiety or depression, whereas others had none. To this day, personality disorders remain difficult to treat. Yet, a large percentage of any psychotherapist's caseload is composed of persons with such disorders, as they comprise approximately 10-20 percent of the general population.

Traditionally, psychotherapists believed that personality disorders were untreatable. This view has changed over time, but whether the view has changed because my profession has become better at treating personality disorders or the view has changed simply because no one wants to admit that a large percentage of  patients are only partially treatable at best is open to question. What I have found in my practice is that most people with personality disorders present with depression or anxiety that can be treated, but that their core personality problems are treatable some, but not all, of the time.

The theories of my profession have held that real psychological treatment occurs in the relationship between the patient and the therapist, and my 20 years of experience has shown me that this is true. The reason that personality disorders are difficult to treat is because the personality disorder has a tendency to destroy the patient-therapist relationship.  Persons with personality disorders have a tendency to hide important information from the therapist, because either consciously or unconsciously, they are unable to admit what they believe to be shameful information or feelings. This is because they either have an inflated ("grandiose") sense of self that does not allow weakness, or they have an inordinate fear of judgment that is a product of their projection.

What is a personality disorder? In short, it is a malformation of the ego, the part of the psyche that mediates between pleasure-seeking urges and reality. We all make emotional compromises to deal with the fact that reality doesn't always give us what we want. A person with a personality disorder, either because of genetic tendencies, a history of early childhood trauma or both that have disrupted normal processes of maturation,  distorts reality instead of compromising with it (people who are simply neurotic, in contrast, engage in "compromise formations" which often involve symptoms that are easily identifiable to both the patient and the therapist).  I have found that many of my patients with personality disorders live in a fantasy world. They are unable to see what people around them are really like because they only see what they have projected onto those people, which may be what they wish others to be like, or, a projection of a  part of themselves that they don't like. Consequently, others may be either idealized or devalued.

There are many other aspects of personality disorders-- this is a complex subject that cannot be adequately explained in a blog post. If you suspect that you have a personality disorder, the path to recovery is to be completely honest with your therapist, even if it feels uncomfortable. Ultimately this honesty breaks down the pathological defenses that comprise a personality disorder, leading to the formation of an acceptance of reality, a realistic self-image, and perceptions of others that aren't so distorted.