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Clinician's Digest

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Conflict Mediation for Siblings

By Garry Cooper

Many parents view sibling conflicts as a proving ground that prepares their children for a world that's not always benevolent or just, and they usually intervene only when they themselves cant stand the ruckus. Although children's conflicts can provide opportunities to find out about sharing, empathy, and compassion, researchers note that those lessons, if they're learned at all, usually come not from communication between the aggrieved children, but through parents autocratic decisions and judgments.

Psychologist Hildy Ross of Canada's University of Waterloo has found that its better for parents and children when parents act as mediators rather than referees, however. Shes developed a model to show mothers how to mediate their children's conflicts in a single hour-and-a-half session.

In a study reported in the March 2004 Journal of Family Psychology, Ross and psychologist Afshan Siddiqui of Toronto, Ontario, found that mothers and children aged 5 to 8 were pleased with maternal mediation, and that the children--including the youngest members of battling sibling pairs--felt more empowered, talked more about their feelings, and tried harder to come up with fair solutions than did control groups who didn't use mediation. Now, writing in the June issue of Child Development, Ross and psychologist Julie Smith of Calgary, Alberta, find that children whose mothers have helped mediate their disputes absorb the technique so well that their subsequent arguments are marked by less acrimony, fairer resolutions, and more awareness of their own and their siblings feelings and perspectives, even when their mothers aren't present.

The training session teaches mothers that they should be impartial and give their children final responsibility for making the decisions that resolve the conflict, and shows them how to introduce and guide their children through the mediation process. With the help of a videotape, role-playing, and handouts, mothers learn to practice and teach such positive communication skills as reframing, active listening, and reflection.

During the mediations, younger children fashioned resolutions almost as frequently as their older sibs, which didn't happen with the control group. Ross and Smith also found that children exposed to maternal mediation were better able to identify their siblings goals and emotions--a significant developmental task for children, even in non-conflictual situations.

Is Therapy Harmful?

In a June 18 Newsweekarticle, Get Shrunk at Your Own Risk, Sharon Begley warns that psychotherapy can harm people. Based principally on a paper by Emory University psychologist Scott Lilienfeld in the March Perspectives on Psychological Science, her article begins by comparing psychotherapy's effects to the dangerous side effects of a few psychotropic medicines. It concludes by quoting estimates that 10 to 20 percent of clients have been harmed by psychotherapy. This totals a greater number of people than were harmed by Vioxx, which the FDA removed from the market, as Begley points out.

But Begley refracted the main focus of Lilienfelds article. He didn't write it to warn about the dangers of therapy in general, he says, although much of his article does review research showing that a dozen treatments--among them grief counseling for normal bereavement, critical-incident stress debriefing immediately following crises, adolescent boot camps for conduct disorders, rebirthing and holding therapies for people who've been deprived of early bonding with parents--probably cause at least occasional harm. Lilienfelds purpose, he insists, wasn't merely to warn mental health consumers and practitioners about these therapies, but also to urge the psychotherapy field to pay as much attention to identifying and researching potentially harmful treatments (PHTs) as it does to identifying empirically supported treatments (ESTs).

It makes no sense, he insists, to focus exclusively on identifying empirically supported treatments, precisely because we know that so many different treatments are effective. Instead, he says, the field should place more emphasis on pinpointing treatments that are demonstrably harmful or ineffective, and conveying this information to current practitioners, students in training, potential clients, managed care organizations, and the media. That will ultimately cut down on the relatively low--but still unacceptably high--10 to 20 percent of people who are harmed by bad therapy or bad therapists.

Regarding how to deal with PHTs, instead of treating them as the black sheep of the field everyone whispers about, researchers and therapists should research them more and talk more about that research, Lilienfeld says. Even harmful therapies work in some cases, and a closer look at their effective components may help develop more effective, less harmful variants. Intensifying the focus will also allow the field to make a stronger case against them, he adds.

The Downside of Black-Labeling

Since the 2003 decision by the Food and Drug Administration (FDA) to put black-label warnings on SSRI antidepressants alerting parents and physicians to the link between SSRIs and adolescent suicides, pediatric prescriptions for the medications have dropped sharply. Many consider this a healthy corrective to years of over-reliance on medications that have troubling and sometimes dangerous side effects and debatable efficacy. But a study tracking pediatric depression from 1999 to 2005 in Junes American Journal of Psychiatry finds a disturbing unintended consequence of the warning: far fewer children are now being diagnosed with depression.

The study finds that since the FDA warning, pediatric depression diagnosis rates have dropped to the 1999 levels of 3 children per 1,000, following a climb to 5 children per 1,000 between 1999 and 2004. Also, fewer children diagnosed as depressed are receiving any kind of treatment. While the percentage of children diagnosed with depression and receiving an SSRI medication has dropped to 28 percent, only 40 percent of children diagnosed with depression are receiving psychotherapy. That leaves a lot of diagnosed children who apparently aren't receiving any treatment.

The study, led by researcher Anne Libby of the University of Colorado at Denver and the Health Sciences Center, points out that pediatric depression cases now fall below expected national incidence rates that are based upon years of epidemiological studies. The researchers speculate that parents, frightened by the SSRI warnings, may be reluctant to seek treatment for their children, fearing they'll be pressured to medicate their children, and that general practitioners, who often diagnosed pediatric depression, have become more cautious about the diagnosis because they fear becoming entangled in the SSRI controversy. Significantly, pediatricians are still diagnosing depression at the same rate, and psychiatrists are diagnosing it more frequently. While some may say its more desirable to leave pediatric depression diagnosis to pediatricians, child psychiatrists, and therapists, thousands of families don't have access to them.

Libby warns that untreated pediatric depression is a serious condition. She points to research indicating that, despite the evidence of a link between SSRIs and occasional adolescent suicides, there's a stronger link between increased use of SSRIs and decreased adolescent suicides. Those studies are more suggestive than definitive, however, because they're ecological studies that don't link antidepressant use and suicide at the individual level. But it does seem safe to say that since the FDA warning, the safety net isn't catching as many depressed children as it should, and too many of the ones caught aren't receiving adequate treatment.

Quelling Interruptions

Family members who interrupt each other during therapy can inflame passions, impede communication, and frustrate the most self-assured therapist. Even an experienced clinical psychologist like Frank Dattilio of Harvard Medical Schools psychiatry department confesses that sometimes hes just wanted to scream and throw in the towel. Instead, hes developed an effective intervention.

Interruptions, says Dattilio, writing in the April issue of The Family Journal: Counseling and Therapy for Couples and Families, create a dilemma for therapists. They derail therapy, but can provide important information. Often people who interrupt aren't merely being rude: they feel that something false or insulting has just been said and that if they don't immediately speak up, they'll lose the opportunity to correct the record. Other times they worry that they wont get to express their spontaneous thought or emotion.

Dattilio now gives members of interrupting families a paper tablet and pencils at the beginning of sessions and tells them that instead of interrupting, they can record their thoughts, emotions, and reactions in any form they want--words, pictures, or symbols. He then assures them they'll have the chance to share later in session. This allows clients to express themselves the minute something comes into their heads and reduces the energy required to hang onto the thought or to interrupt. If the desire to interrupt is particularly strong, he suggests that they draw symbols like asterisks next to what they're writing.

Resilience in Adolescent Psych Wards

You wouldn't expect that adolescents who've had a psychiatric hospitalization would, a few years later, score as high as their young adult peers across a battery of measurements on psychological well-being. But some do, and an intriguing new study looks at why.

Between 1978 and 1983, psychiatrist and psychologist Stuart Hauser and his colleagues collected the narratives of 146 adolescents and annually reinterviewed them and their families as part of a longitudinal study of adolescent development. Then, in 1989, new researchers, who knew nothing of the now young adults histories, interviewed them again. Upon learning during the interviews that some of their adult subjects had been psychiatrically hospitalized as teens, interviewers expressed surprise at how emotionally healthy and well-adjusted they were.

The hospitalized teens, although nonpsychotic, had gone through severe traumas that should have permanently derailed their psychological development. Although only 9 of the previously hospitalized subjects scored in the upper half of the 146 subjects studied on a battery of psychological health measures, the results were unexpected enough that Hauser, from Bostons Judge Baker Children's Center and Harvard Medical School, and psychologist Joseph Allen of the University of Virginia, went back over the years of narratives to search for clues about why these few did so well.

The results, which appear in their book Out of the Woods: Tales of Resilient Teens, to which child psychiatrist Eve Golden contributed, and in the January issue of Psychoanalytic Inquiry, suggest a complex interaction between the ways that resilient adolescents view their lives and how they form relationships. In their personal narratives, they present themselves as people with what Hauser and Allen call a sense of agency: they think about the role they play in what happens to them, and they're more insistent than the other interviewees that what they do and think matters. Of course, this behavior, which sounds admirable and healthy, can also be labeled as defiance in the locked-down world of psychology units. Their narratives reflected more upon their own thoughts, feelings, and motivations, and were more likely to describe their relationships than their nonresilient peers narratives did. Finally, their narratives are more coherent and compelling.

The interest level of these nine subjects narratives, their propensity toward establishing relationships, and the fact that some of them went on to develop and add to their life narratives through the years suggests a connection among narratives, bonding, and resiliency, says Hauser. As all storytellers know, people who tell more compelling, coherent stories tend to attract listeners. This, he thinks, creates more interpersonal connections, which furnish additional building blocks for narratives. Narratives and relationships, he suspects, may create an ongoing feedback loop that helps create resilience.

Rage and Anger

We take for granted the notion that raging people are angry people. But therapist Ronald Potter-Efron of Eau Claire, Wisconsin, who works with ragers, says they're feeling threatened rather than angry. This distinction has important implications for treatment.

The notion that rage is threat-based raises the hackles of many people who work with victims of domestic violence, who insist that violence and anger are methods of control. But there's some intriguing empirical validation for Potter-Efrons theory. In the September 2006 issue of Legal and Criminological Psychology, British psychologists Elizabeth Gilchrist and Ian Mitchell review physiological and narrative research suggesting that some domestic batterers are indeed experiencing panic attacks rather than anger.

In his book Rage: A Step-by-Step Guide to Overcoming Explosive Anger, Potter-Efron posits two broad categories of rage: sudden rage, in which people seemingly explode in a violent transformation reminiscent of Dr. Jekyll and Mr. Hyde, and seething rage, which gradually builds and then erupts, volcano-like.

For each type of rage, Potter-Efron recommends different cognitive-behavioral or focusing interventions. But the work begins by discarding the old paradigm of ragers as controlling manipulators. Anger is goal-directed; rage is threat-directed, he says, pointing out that the most common reaction of raging people to their rage problem is despair.

Noting that even sudden ragers have some early-warning signs, he helps them recognize those signs and develop a safety plan that includes gathering together a support system to call on for help. They should also consider medication. Surprisingly, he says, antiseizure medications, not tranquilizers, seem more effective. Brain scans indicate that both rage and seizures involve temporal lobe activation, which antiseizure meds quiet.

Seething ragers, notes Potter-Efron, should practice calming techniques daily. They can benefit from introspection to learn about their triggers and examine what their long-term resentments are.

Seeing raging people as feeling threatened and powerless rather than as manipulators helps break down the therapists distrust (or even anger) toward them, and may make it easier to establish an empathic connection. The threatening feelings that fuel rages, Potter-Efron says, come from four fears: fear of not surviving, of impotence or powerlessness, of abandonment, or of shame.

A Depression Vaccine?

Important scientific discoveries usually result from years of cautious hypotheses and the slow accretion of information. But sometimes they come from accidental events. Some recent research raises the possibility that a common vaccine used to treat tuberculosis, Crohns disease, rheumatoid arthritis, and other conditions may actually vaccinate against depression.

Mary O'Brien, an oncologist at the Royal Marsden Hospital in Sutton, England, was researching whether Mycobacterium vaccae (M. vaccae) could improve lung cancer survival rates. Although the vaccine didnt affect survival, OBrien noticed that people treated with it reported significantly higher scores in cognitive functioning, vitality, emotional health, and other quality-of-life measures. The finding intrigued Christopher Lowry, a neuroscientist at the University of Colorado in Boulder, who was aware of a puzzling paradox about diseases related to the immune system: although people with such diseases are often clinically depressed, their immune system activation is actually accompanied by an increase in serotonin levels. Lowry wondered whether there might be some connection between M. vaccae and serotonin levels in people with overstressed immune systems.

In his study, reported in the May issue of the journal Neuroscience, Lowry vaccinated mice with M. vaccae, then measured their serotonin levels and their responses to stress. As he suspected, when placed in water, the vaccinated mice swam much longer than the unvaccinated mice. (Increases in swimming in this behavioral test reliably predicted the antidepressant properties of other medications.)

Lowrys precise measurements of serotonin levels--not just the quantity, but the particular brain regions where he noticed the increase in the vaccinated mice--provide a key to the puzzle and offer tantalizing support for his hypothesis that M. vaccae might someday prove to be a vaccine against depression. He found evidence that M. vaccae affects the less common of the two types of serotonin neurons: Type II, found in only one small region of the midbrain. Type II neurons are thought to be more directly involved in activating the bodys stress-coping system. Stressed immune systems automatically respond by pumping out serotonin to counteract the stress. But because immune systems constantly under stress dont have time to recover, this chronic overactivation eventually leads to periodic serotonin depletion. M. vaccaes antinflammatory properties, Lowry says, may prevent the immune system from becoming overactivated in the first place, preventing the cycle of excessive serotonin production and depletion.

Obviously there's a lot more research to do before determining that M. vaccae can effectively vaccinate subjects against depression, but Lowrys preliminary study opens up a new area for depression research.

Resources

Mediation: Child Development 78, no. 3 (May/June 2007): 790-805. Harmful Therapy: Perspectives on Psychological Science 2, no.1 (March 2007): 53-70. Downside of Black-Labeling: American Journal of Psychiatry 164, no. 6 (June 2007): 884-91. Interrupting: The Family Journal: Counseling and Therapy for Couples and Families 15, no. 2 (April 2007): 163-65. Resilience: Psychoanalytic Inquiry 27, no. 1 (January 2007): 549-80. Depression Vaccine: Neuroscience146, no. 2 (May, 2007): 756-72.

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