Clinical News You Can Use

Adult ADHD: Medication Plus Cognitive Behavioral Therapy, Latest Research

An article by Sanjay Gupta*, “Talk Therapy Alone for ADHD Doesn’t Cut It,” reviews a recent multi-site study of treatment for Adult Attention Deficit Hyperactivity Disorder [ADHD]. In sum, “talk” therapy does have a significant benefit, but it doesn’t benefit ADHD symptoms quite as much as medication or the combination of medication plus therapy.

Treating ADHD means BOTH

adhd11) improving symptoms of concentration, focus, and memory with medications AND

2) developing skills for organization, social behavior, following-through, remembering responsibilities, and anticipating consequences.

The research addressed mainly the symptom domain.

We have known since the 1980s that “psychosocial” therapy, such as individual psychotherapy, group therapy, or social skills training, does not significantly reduce the symptoms of most children with ADHD unless medication is also used. The most common medications for children with ADHD are formulations of one of four drugs,

1) methylphenidate (e.g., Concerta, Daytrona, Focalin, Metadate, Methylin, Ritalin),

2) dextroamphetamine (Adderall, Desoxyn, Vyvanse),

3) atomoxetine (Strattera), or

4) guanfacine (Intuniv, Tenex).

A child may do well on the first drug chosen. But often, one drug may have unwanted side-effects or weak benefits for that child. So then a different one of these drugs needs to be selected. Sometimes, the child benefits more from taking the drug twice per day. Depending upon other behavioral symptoms besides those of ADHD, some children receive a second medication, such as Clonidine (catapres), riperidone, or an anti-depressant.

Adult ADHD Outcomes

The recent German study published by Alexandra Philipsen, et al, in JAMA Psychiatry shows the same is true for adults with ADHD, adding medication produces more benefit than therapy alone. The researchers adhd2analyzed data from 419 patients who had been randomly assigned to one of these four conditions: methylphenidate, individual therapy, structured cognitive behavioral group therapy, or placebo. Simply stated, the methylphenidate group experienced larger reductions in symptoms than patients in the two therapy conditions. The main measure was the ADHD Index of the Conners Adult ADHD Rating Scale.

The implications of these findings are of special importance for mental health professionals and ADHD patients.

  1. A reduction of 20-25% in symptoms can be achieved by a combination of therapy and medication.
  2. Medication should be added to the treatment regime in order to boost the improvement.
  3. Realistic expectations are important. The state-of-the-art approaches lead only to modest gains in ADHD symptoms.

The study only measured the overall ADHD Index on the Conners. (CAARS) Note that in addition to measuring how closely the patient’s symptoms match DSM-IV symptoms for ADHD, the Conners also measures various adhd3other symptom domains as well.   We present these in order to clarify that a person with ADHD has both SYMPTOMS, as measured in the study, and IMPAIRMENTS, that is, areas of functioning which are limited by ADHD symptoms.

1) Inattention-Memory Problems – Since Working Memory deficits are thought to be central to ADHD, many patients have problems with concentration, short-term memory, forgetfulness, absent-mindedness, disorganization, and planning.

2) Hyperactivity/Restlessness – Many, but by no means all, patients feel or appear restless and have trouble sitting still.

3) Impulsivity/Emotional Lability – Many experience rapid shifts in mood (not to be confused with Bipolar Disorder), irritability, making snap choices without stopping to think about consequences.

4) Problems with Self-Concept – Lifelong difficulties with relationships, academic performance, and choices lead to a loss of self-esteem, a poor sense of competence.

The study did not determine if the treatments led to improvements in the adhd4range of domains and impairments. Nor did the study look at long-term skill improvements specifically. However, since Conners scores did not go down much in the study overall, we see that, without medication, patients lagged in the acquisition of new skills.


In recent years, an industry has arisen using coaching as an intervention with adults with ADHD. Motivated individuals can benefit from coaching or working with a psychotherapist to improve follow-through, completing important tasks, social interaction and relationships, and self-concept. The Philipsen study suggests that medication may enhance the ability to learn these crucial skills.

Lastly, ADHD is a lifelong condition. A person with ADHD learns

*to manage the symptoms

*to overcome the impairments,

*to acquire skills for effective performance in school, work, partnering, family life, and in the community

The study should not be read to mean that medication alone if the answer. Therapy or coaching is essential to helping many ADHD patients to manage the social, occupational, and educational effects of their primary ADHD symptoms.

*Click here to read the Sanja Gupta article.

Click here to read the abstract of the Philipsen article. 

The entire article reference is:

Philipsen A, et al (2015). “Effects of group psychotherapy, individual counseling, methylphenidate, and placebo in the treatment of adult ADHD. JAMA Psychiatry, 2146.

If you have more interest in the Conners Adult ADHD Rating Scale (CAARS), here are two sites which give examples of scoring for the CAARS and a breakdown of the symptom domains measured by the Scale, which include the major areas of difficulty in adult ADHD. The scale itself is only available to trained mental health professionals.

CAARS: Long Version (CAARS-S:L)

CAARS: Short Version (CAARS-S:S)

If you want to dig deeper into the professional literature on Cognitive Behavioral Therapy for ADHD, a good place to start is this review:

Knouse, L.A., & Safren, S. (2010). Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder. Psychiatric Clinics of North America, 33 #3, 497-50

This link to the Knouse and Safren article on PubMed brings the reader to a number of other articles on this subject:

Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder


Therapy Gems: It’s Okay to Be Yourself in Progress Notes

I never knew myself as “Wr.”

I never referred to myself in written psychotherapy documents as “This Writer.”

The term “This Writer” has always felt to me to be discordant, as dissonant as screeching. sbh1

As it seemed to be a harmless practice, I did not tell my trainees to change the habit of referring to themselves in the third person, and I failed to examine my reaction in depth.

A few days ago, Lynn Godec and I were reading the notes of a client we needed to refer after her therapist decided to move out of the state. Reading this note, Lynn and I together grasped the deeper meaning of my displeasure at the terms “Writer,” “This Writer,” or “Wr.”  The therapist’s initials are LY.  The client is referred to by name, by her initials, JZ, or by Cl.


Cl came for the first of three final individual sessions. Wr. informed Cl at the end of last session that Wr. will be leaving at the end of the month.  Wr. and Cl spent most of the session processing this event, including Cl’s feelings of loss and disappointment, as well as Writer’s recommendation to transition to another therapist in the clinic.   Cl has hx of depression and SI, but reported no SI in this session.  She said she understood, and that she has had to change providers in the past.  Cl is open to Wr’s suggestions.  She reported since last session she was at the ER as a result of a bout of fear, tachycardia, and difficulty breathing which turned out to be one of her panic attacks. Wr. connected that event with the news imparted in last session.  Questioning uncovered her projections around why Wr. was leaving, which Cl had personalized.  Worked on a cognitive restructuring task and forecast other feelings about this transition would come up, to please bring that to the next session.

DR: For such an emotionally intense experience, doesn’t “WR” sound kind of distant.

LG: Yes, it seems too objective sbi2

DR: It’s odd.  It denies the intimate connection that Joy (meaning the client) feels, her anxiety, like there isn’t a relationship.

LG: The whole point of the note is the meaningfulness of a relationship and attachment for the client.  If the therapist wants it to sounds to objective all the time, that practice troubles me.

DR: Exactly.  Oh, if the therapist did it so much in this one session, more than in other notes, we could guess she is having a problem with clients’ feelings about her leaving, or is ambivalent about leaving.  It is a hard part of professional life to change jobs, to say goodbye to 30 clients and help that many new ones at a new job all in a couple of months.

As the conversation continued, I realized that in my job in business management before I went to graduate school, I followed the practice in business correspondence of using the first person. If I were giving my opinion, facts, or a promise, I referred to myself as “I.”  If I were referring to a process involving others at the company or a company commitment, I used the first person plural, “We” or the name of the company.

From day one of graduate school, I trained as a psychotherapist. My only jobs in the field over four decades, all three of them, were therapy jobs. The first was as a therapist on an inpatient unit.  The second was in a non-profit clinic. The last 25 years have been in a solo practice which morphed into a large private therapy clinic.  I had not trained in one of the many professions that therapists often do before becoming psychotherapists, especially, nurse, teacher, school social worker, protective service worker, case manager, discharge planner, residential treatment therapist, autism line therapist, psychometrician, and others.  Perhaps in some of those settings, therapists learned to speak of themselves in the third person.

On the other hand, I always referred to myself in notes as “I” or by my initials, “DR.”  For variety, I use “T” for therapist, but mainly to indicate a back and forth dialogue between Cl and T.

DR: Writing notes is almost more subjective than objective. We are not video recording the session.  We choose what to write, what’s salient, want we want to remember, how we will describe what happened.  We analyze the session and record what our clinical thinking tells us is important.

LG: It’s like trying to sound objective by using the third person, as if the therapist were watching the two parties interact and describing that from a step removed from being there.   S, that makes me wonder if therapists who write that way try to place themselves in that stance with the clients!

DR: That’s a scary thought.


So I think we nailed it. Psychotherapy is a process in which the healing factors are a strong therapeutic relationship founded upon these factors:

  • genuineness
  • emotional honesty
  • positive regard
  • empathic attunement
  • instilling hope
  • a therapeutic alliance based upon rapport, the result of all these relational factors, and client-therapist agreement on the goals and methods

Interactional subjectivity, on the one hand, and self-observing objectivity on the other must be present together.  Client and Therapist are in an experiential relationship, the interactional, subjective side, and the therapist is paying attention to the process between them and the process inside each of them, the self-observing, objective side.  However, making the therapist an object also objectifies the client.   That does not seem to fit with the core healing factors.

DR: It feels like “Writer” is a violation of what therapy is about.   I wish our staff would write notes that show how well they are interacting, that they are connected with the client.

LG: Try re-writing that note. See if it makes a difference.


Joy came for the first of three final individual sessions. At the end of last session, I told her I will be leaving at the end of the month.  We spent most of this session processing this upcoming event, including Joy’s feelings of loss and disappointment, as well as my recommendation to transition to another therapist in the clinic.   Cl has hx of depression and SI, but reported no SI in this session.  She said she understood, that she has had to change therapists in the past.  Joy is open to LY’s suggestions.  She reported since last session she was at the ER as a result of a bout of fear, tachycardia, and difficulty breathing which turned out to be one of her panic attacks.   LY connected that event with the news imparted in last session.  Questioning uncovered her projections around why LY was leaving, which Cl had personalized.  Worked on a cognitive restructuring task and forecast other feelings about this transition would come up, to please bring that to the next session.

Reading version I, I feel closer to the interaction.  An important therapeutic byproduct is sensing I sbh4have a better grasp on the client’s process.

DR: I feel I sense Joy more, understand her better. Feeling her more directly in the first person makes it easier to see what is happening with her.

LG: So, as the author of the note, we aren’t writers; we should write like we are therapists.

Just to be sure it makes a meaningful difference, I read the two notes to a few non-therapists. Here is a sampling of some comments.

“The second one is comprehensible.”

“The first one is confusing.  I had to ask a lot of questions to grasp what she was saying.”

“The second one is more insightful.” I pointed out the content is the same.  “But it feels it has more insight.”

“The first is just inappropriate.”

“That writer is not a writer.  She’s a therapist.”

“It’s like putting the therapist four steps away from her place as therapist.”

“I would not want to see that therapist.  I don’t see she cares.”

So, I am not the only person finds the wording “This writer” to be incongruous with the role of therapist.

My recommendation is that therapists write notes in the first person and my hope is that no one causes me to read such dissonant notes anymore.

P.S. While I am discussing the use of “Writer,” I will add that the word “Provider” has troubled me since around 1988-1992 when the term came into common use.  Our status as Psychologist, Clinical Social Worker, Licensed Counselor, Marriage and Family Therapist, etc., was changed by Managed Care Organizations to “Provider.”   To the MCO, we are all roughly equivalent.  The first tier consideration for how referrals are doled out is by zip code.  Specialty areas are second-tier factors.  Actual profession is not a significant factor in the process.   Strikingly, professionals seem to have accepted the appellation of “Provider,” have signed “Provider contracts,” and, in the case of those companies for which is it difficult to  become a “Provider,” welcomed the opportunity to be on the “Provider panel.”  All that is necessary to survive in the profession; if we want to be paid for our work, we have to do this.  I am not suggesting we all rebel.  What I am suggesting is that we be proud of the arduous paths we have taken to get to be psychotherapists. I am also suggesting we attend to a larger subject, namely, care in the use of language.  Just as the connotative meaning of “writer” can be dissected and produces a different experience than “I,” so too “provider” produces a different experience than “psychotherapist.”  My hope is that therapists will become more conscious of the way in which they use language.

In the News: 30,000,000 Words

At a child’s birthday party one afternoon, while a few of us older folks were watching the kids play words pic1soccer and color masks, we were in essence discussing child development. The advancing skills of these children, aged four to six, amazed us. They were learning to play by rules, kick the soccer ball with authority, paste stickers in neat designs, cooperate, share, and focus. They made up cooperative rules for competitive games. They played together without frustration, aggression, or injuries. They played with almost no adult supervision.

Disparity in Childhood Verbal Experiences

Just as amazing is the realization that most children in this age group could master many of these self-control, self-regulation, and social interaction skills. The children we watched are from professional families. That brought to mind a remarkable piece of research. I referred to the study contrasting these children of affluence, from highly educated families, with the many children we see in the clinic who come from less well-off families which have less educational attainment. As I recalled, a study showed a three million word difference between how much verbal input higher income-higher education families provide their children by age four as compared to low income- lower education families. These are the words of interaction from the parents.

I was startled just repeating the number. The others were astonished by that magnitude of difference.

Later, a teacher at the party pointed out my mistake. That figure is not the enormous number of 3,000.000.

No, I was off by a factor of 9, namely, 27,000,000 words. The true figure is 30,000,000.

Thirty Million Words

I double checked the information. Indeed, a long term study by Betty Hart and Todd Risley found the difference by age 4 is 30,000,000 words, about 1200 words per waking hour throughout the first 4 years. Even if we criticize the study on the basis of a small sample or the manner of extrapolation from the limited observations in this study to the child’s entire early life experience, and even were we to do the study with a larger sample, the difference likely to be found in subsequent studies is still going to be so very enormous.   Plus the difference between these class groups is fairly stable over time.

The impact is that by age three, the vocabulary of children from the highest educated group exceed that of the lower economic group by a factor of 2 or 3.

Not only did the less advantaged children have smaller vocabularies. They added new words more slowly. In other words, the gap continued to expand.

Gaps remained mostly stable when the kids who were 2 or 3 were measured again at age 9 or 10. We know that vocabulary size is associated with higher levels of income and attainment. Hart and Risley raised the concern that children in the least advantaged circumstances may not have the vocabulary needed for understanding standard books and high school textbooks.

words pic2

Furthermore, educational efforts to overcome the disparities were dwarfed by the impact of family communication patterns. Educational experiences did not significantly close the gap.

The children in the study were observed interacting with their families. The children were equally nurtured and well cared for regardless of economic status.. So the findings cannot be attributed to factors other than the amount of verbal communication in the family.

words pic3

A Discouraging Word

We know that positive reinforcement, celebration of achievements, approval, recognition, and the expectation of succeeding are powerful motivators. Children often need a push in order to try tasks that are difficult. They need positive reinforcement for their new skills and learning. What might happen if they received less of those important positive words and far more negative words – words which prohibit activities, criticize performance, or point to what was not going well?

Children tend to live up to (or sometimes down to) what is expected of them. Expectations of success are often met with greater effort. Expectations of failure can be demoralizing. So the study’s findings about positive versus negative motivators were also astonishing. In the study, it was not merely the volume of words which differentiated the groups. Along with the sheer number of words, Hart and Risley counted words of encouragement and praise versus words of discouragement. They found a large difference in how much praise and encouragement children receive. Higher economic status was associated with about six words of encouragement to each word of discouragement. In working class families, the ratio was about 2:1, meaning life for those children was far less encouraging.

For thirty years, the authors had been focusing efforts on helping children from poorer families to achieve higher educational attainment. Much of their work was at a center which worked with children from poor families or on welfare. So, in what they termed “welfare” families, the ratio of encouraging-to-discouraging words was reversed from other families, that is 1:2, meaning twice as many discouraging words which, in effect, totally dominated the positive words. The authors observed a phenomenon we often see in the clinic, namely, these families used far fewer parent-child interactions, with more of the focus of interactions being centered on prohibiting behaviors, on socialization, and on disciplining. It is not that other families neglect these interactions, but they are more likely to control or socialize by reinforcing desired behaviors and encouraging appropriate responses.

Furthermore, higher economic class families spend a lot more of communications expressing encouragement, with its connotation of higher expectations.   In the professional families, the children heard 560,000 more words of encouragement than discouragement over four years. The gap for a working class family was only 100,000. The raw number of positives was less than half of that in the higher income families. So those children received a great deal less of positive reinforcement and positive expectations.

Children in the ‘welfare’ families received 144,000 less encouraging words than discouraging words. That means they heard 300% more discouraging words than the children from the more educated homes. The number of encouraging words was also far less than those heard by working class families, actually about 140,000 fewer.

words pic4

Lastly, the authors report the ‘welfare’ families showed far fewer “back-and-forth” conversations, more one-way conversations. This tends to sound as if effort, abstract reasoning, presenting a reasoned argument, discussion, and listening to children were less valued in those families.

We know that a baby’s brain over-produces neurons, those potential connections it will need in life. Then the brain prunes away potential connections which prove to be unnecessary for adaptation to the child’s environment. We know that an enriched early environment leads to more connections, meaning more memory, more verbal capacities, more learning. The brain whose adaptation is stretched in order to manage a richer environment should be better able to manage a variety of environments in the future and to accomplish more problem-solving, more achievement. In earlier life, this would translate into higher school readiness by age 5. In the study, it translated into higher educational outcomes across the board.

Clinical Implications

We want to put these stunning findings to use in our work. Where Hart and Risley are concerned with early childhood education, we are concerned about mental health and behavior change. Psychotherapy has often been mainly a verbal endeavor. But this study is a reality check on the methods clinicians value.

  1. Our methods must be adapted for children who may not be as verbally-oriented as may be needed for standard individual therapy or even for cognitive therapy. Clearly, in clinical work with children, we should always check that the child fully understands the clinician’s comments. Children may take language which is figurative in its concrete sense. We also assume children use oral, verbal methods for thinking through problems and making changes. But that may not be the preferred channel for behavior management for the child and family where the child is not used to positive verbal management of behavior.
  2. Also cogent is the finding that the parents and children are highly matched in verbal patterns. More of the families in the study relied on approaches which are only somewhat positive and encouraging or predominantly not positive at all. Since we know that positive reinforcement of behavior increases its frequency, and we know it is a more effective strategy than punishment, so our methods must help transform family interaction toward the positive. That means reinforcing both generations for positive behavior, the parents for positive strategies and words as well as the children.
  3. Many parents will expect a “disciplinary” or punitive or negative approach. We do not want to argue about that. It may be that the alternative we offer is outside the family’s framework. The clinician will need to find ways to demonstrate a new approach and to shape new interactional behavior without using persuasion or argument.words pic5
  4. When we use play or activity-based methods of therapy, it seems we should verbally mediate the play – labeling every feeling being expressed, re-stating the child’s actions in words, highlighting in words each skill used by the children. By verbalizing, we are demonstrating a new way of interacting. We are also increasing the reproducibility of the behavior. The same principle applies to the behavior of parents!

I leave it for others to think of even more creative or effective ways to use the 30,000,000 word findings.

For more information, check these sites.

Hart, B. & Risley, T.R. “The Early Catastrophe:The 30 Million Word Gap by Age 3” (2003, spring). American Educator, pp.4-9


The Lingering Effects of Teasing and Bullying:

I. Traumatic Impacts

Bully pic 1I asked Howard, a 60 year-old man with a history of depression, about the social shyness for which he sought my help. Then, he told me the story of how he had been teased and bullied years before.

“When I was in the fifth grade, we moved from a neighborhood where I’d grown up the first 10 years f my life. I had friends and felt pretty good about myself. One of the fastest runners in the school, I could hit a baseball far for a 10 year-old. In retrospect, I guess I felt very equal to my friends. It was back at a time when kids had free run of the neighborhood from the library about half mile away to the big park across a busy street to a neighborhood shopping strip a few blocks away where there was a popular deli. My father used to take me there for breakfast before we would go for an outing on a Saturday. Or give me ten dollars and a list of things to buy from the bakery counter and bring home.

“Then we moved up to a more affluent area where the kids were way more sophisticated than where I had grown up. They dressed in the latest clothes, knew all the latest popular music, even knew how to dance. The athletic boys knew how to play basketball. There was no basket in the play ground at my old school, and I didn’t know anything about the game.

“So, I remember being teased by the popular kids for what we would now call being a nerd. How being clever turned into a bad thing puzzled me completely. My clothes didn’t fit in; I was ashamed of that. Someone teased me for my facial features, which were ordinary, I guess. I have to admit that a couple of years later I joined in picking on another kid for his looks. I guess we knew we were being cruel for no good reason. No, I didn’t have one particular villain. Just that there were several kids who had nothing to do with me except to say derogatory things. That hurt.

“But there was this one kid, Billy, a real troublemaker, who took everything one step farther. He was scary. He ended up in a reform school. That’s what they called it in those days, you know, for the dangerous kids. If one kid would only go so far as to say I was a bookworm – an old term for nerd, I guess – Billy went further, knocking the books out of my hand. Once, he knocked them into a puddle. If a kid might just say my nose was too big, that Billy put his palm over my face and pushed me. He always took it farther than anyone else. If some one said something about my clothes, he’d pull me by a shirt, ripping off a button, or yank the back of my collar until I fell. A real piece of work. We was a mediocre athlete, but he liked to show off that he had the best looking girlfriend or the biggest entourage. So, he would come by the school yard, but not right after school. Later. So, I got to play baseball or learn basketball. I knew to clear out by 4:30 or so, if I remember right, and keep out of his way.

“I tried so hard to excel at what seemed important there. Like learning to dance. Spending hours learning to dribble and shoot baskets and field baseballs. I got some cool clothes – one of the kids who befriended me showed me how to pick.

“But I became a follower, and did not have the same level of self-esteem as in the old neighborhood. I became self-conscious, I always worried about my impression on others. I still am. That was not part of my thinking before moving there. So, then I got to be shy in the sense of afraid to approach people. I thought they would feel I was a bother. I defined myself as unpopular. That’s what I was. My friends could criticize me and I’d take it; I’d think there actually was something wrong with me which I had to fix. As time went on, my distance from the popular kids became a universe; so I just thought of myself as part of the unpopular and different group.

“Even over four decades later, what stands out most immediately from those days is the memory of the ‘lowlights!’ I mean the various teasing comments. I can remember a lot of good things, but the unpleasant stuff is what comes up in my mind first.

“It was not just the kids. My three most immediate memories of high school are a teacher of Spanishbully pic 2 mocking me on the first day. It seems the teacher from the previous year must have said to her that I was good in Spanish and I raised my hand a lot. So a source of self-worth by being smart got put down on the first day in her class when she said in a critical way which was, I am sure, meant to put me down, “Oh, Howard ______, I heard about you, yes, Howard _______, I heard about you.”

“I remember feeling now there was almost nothing I could do to be accepted anymore. An English teacher made fun of me in class for a silly mistake on a test. I guess being a good student gets you blasted when you screw up. And a physics teacher did the same. I had winged it on a test – my fault for not studying more – and got a very poor grade. But the teacher didn’t have to announce it in class. I spent a week feeling two feet tall.

“After that, I felt equally bad when I aced a test and set a curve. Like no one would like me for that.”

“Fortunately, the skills I had shown when we moved to the neighborhood, which included spending hours practicing and a determination to master skills, helped me a lot. In my mind, getting near perfect grades in physics, a compulsion with me the rest of that year, showed up the teacher. Of course, that’s how the bullied think, that any future performance is in some kind relationship to the teasing. Proving you are better than they say. Or confirming you are as bad as they say. Now, it dawns on me the teacher probably felt reinforced by my improvement; she could get the impression that, if you mortify the kid, then he’ll do better!

Howard concluded, “I’ve been reasonably successful. But still I am afraid to approach people for fear of what they may say. Still I wonder if someone will sting me about my hair, of which there is obviously so much less, or my features or my clothes. So I pay too much attention to trying to impress people with my sports car, my bold colored clothes, art work, my upscale address, being in shape, playing great golf, trying to fit in. It’s a battle that can never be won. Each day that feels good and I think I am something special runs into the next when I am low and have to prove myself. So I’m depressed.”

Brittany told a different story.   At 56, she told the story of events 40 years before. More emotional than Howard, she was too upset to get into all the details. “I was slow to mature. So already when I was 13 or 14, I was noticed for being different, the outsider. But then the acne came. All kids got it in those days. Is it my imagination or it way less prevalent today? Look,” she said, pointing to her face, “pock marks. Lots of them. That’s why I wear a lot of make up.”

“The boys would call me names I won’t repeat. The girls, well, some took pity, which made me feel worse somehow. A few understood. There just wasn’t much you could do for it. Antibiotics. Washes. Visits to the dermatologist. Didn’t help all that much.

“Then there were the girls – nowadays we would call them ‘Mean Girls.’ Wow. They were brutal. I also had big cystic pimples on my back and the girls could see that in the locker room. They said and did things to make me feel contaminated, like it would infest them. I still can’t stand being looked at too much.

In fact, Brittany did far more to compensate than her story suggested. She developed an obsession bully pic 3with her appearance and a ritual compulsion to armor herself with medications, makeup, scarves, and a hairdo which would mask her scarring as much as possible. She had to get up an extra hour early in the morning in order to go through the ritual. Spontaneity was forbidden in her world.

These stories came to mind when I read a Chicago Tribune article, “The debilitating scars of bullying” by Candy Shulman (February 8, 2015)*.   Her brave disclosures demonstrate the inner experience of someone being teased. She notes that some years later, the bullied continue to think about the mistreatment while the bully often remembers nothing of his or her behavior.

Shulman’s story mirrors the stories of Howard and Brittany*. Particularly noteworthy is how the object of teasing and bullying develops a mindset that she is being bullied and has to protect herself from it even when it is no longer happening. Shulman thinks of it as a victim mind set.

She also points out how bullying shapes social perception and expectations. For example, she mentioned the expectation of hurt and loss, behaviors engendered by her childhood bully, which generalize to new situations later in life and throughout adulthood.

Similarly, Howard and Brittany spent their adult lives continuing to stave off teasing and trying to achieve a feelings of acceptance, feelings of which they had felt deprived during adolescence. Each forecast a likelihood that new situations and new people would treat them in the same humiliating and hurtful ways as they had experienced in adolescence. They compensated in ways they imagined would fend off attacks. This is classic avoidance behavior – continue to react as if the assault is coming even after the threat no longer occurs. We carry the threat around mentally and act as unremitting victims.

One of the most extreme reactions to bullying is to identify with the perceived violence of it and then to perpetrate violence upon the self or upon others. That makes the news. Suicidal thinking and suicidal actions as a result of bullying are amongst the strongest of reactions to it. Completed suicides attributed to bullying are often reported by the media. Mass shootings by teens and young adults are often explained as associated with chronic bullying. They have led to a movement to shift the attitudes of educators from overlooking bullying or rationalizing it to the expectation they will prevent it or stop it.

But one in five children report being bullied. Sometimes, the damage may be significant enough tobully pic 4 shape lives, as we see with Howard, Brittany, and Ms Shulman.

In these days, one can cyber-bully, namely, leave teasing or hurtful comments on the Internet or in a chat or email or on Facebook. The cruel words do not vanish, but remain visible. Rather than delivering teasing in person, the comments can be hurled from a safe distance.   I wonder if that makes it easier to issue teasing. I wonder if the words are more impactful when on the Internet.

bully pic 5Another example comes to mind. Jesse* was 16 when his mother brought him to see me. It was March. He went to school for sophomore year for about two weeks back in September. Since then he had not been back to school. This was before schools had to have programs for children who were unable to go to school due to illness or, in Jesse’s case, emotional problems.

I had previously treated a number of children with school phobia, a form of separation anxiety in which the child is afraid to be away from parents or home. Often the child fears some dire event may take place when he or she is away or the parent may leave the family.

With Jesse, we found no evidence for school phobia. He was depressed, sad, and soft-spoken. He showed little emotion overall. A behavioral analysis of his problem with school showed that he feared two situations. 1) If kids in the hallways were loud, the noise startled him. He expected a fight would break out. He assumed it would become violent, and he could be hurt in the melee. While he had seen fights, he had never actually been harmed. 2) If he walked into class and anyone was already in the room, he expected to be watched and judged. He thought the other kids would think he was strange. He would feel embarrassed. He then thought that he would be singled out to be victimized. The escape from social situations due to the fear of being judged by others is a symptom of a mental disorder known as Social Phobia.

That particular situation in class had actually never happened. However, he had often been teased by an older brother. So the memory of that teasing was being generalized to the school setting. Furthermore, Jesse believed his father sided with his brother. So Jesse generalized that school employees – teachers and administrators – would not protect him. He expected they would join in the negative behavior. So in his world, there was no protection except to avoid the situation and hide at home. In his belief system, he had defined himself as a vulnerable victim.

At home, he did not feel entirely safe. His imagined fears made him anxious even there. But he felt relief that as a result of his avoidance no new episodes of harm could occur.

In order to motivate him, Jesse’s father took a stance many parents might take. In hopes of motivating the young man, Father admonished him, told him that at this rate he would not amount to anything, and said high school should be a good time in life. To Jesse, however, these efforts confirmed his feeling of being misunderstood, unprotected, and not measuring up to other children. In contrast to Father, Jesse’s mother tried to comfort him. She pleaded with him to go to school. She felt helpless to motivate him. As a result, many days would pass when she said nothing about his avoidance. When she backed off, Jesse experienced what we call intermittent negative reinforcement, namely, the relief that he could stay home while the unpleasant interactions in the family would not occur that day. Such avoidance behavior is remarkably stable and long-lasting.

bully pic 6Jesse’s mother had gone to school to complain to the Assistant Principal. However, the latter did not give her and Jesse a sense that the young man could be protected. Rather, the school threatened the family with repercussions for their son’s truancy.

In contrast to school phobia, Jesse presented with Social Phobia and school avoidance, failure to attend school due to a fear of the school setting or of other children. He had experienced some teasing, and he had witnessed bullying.

Can one be affected vicariously by witnessing bullying? Yes, indeed. Jesse projected himself into the shoes of kids he witnessed being bullied. He imagined what it would be like if that happened to him. He felt terrified by his thoughts. He imagined the helplessness that he felt standing by as a witness would be magnified if he were the actual victim. By remaining on the periphery of his school mates, he had few ties at school to motivate him to go just for positive social interactions with friends.

Whereas Howard’s and Brittany’s stories show the lasting effects of teasing and bullying, Jesse’s story shows the impact at the time it is happening. It even shows how witnessing others being bullied can affect bystanders. The story demonstrates how difficult it can be for parents to select an effective strategy to manage the situation.

The good news here is that Howard and Brittany had compensated effectively. So for them, the task in therapy was to help them desensitize the memories, change beliefs about themselves, and free themselves to experience contemporary life as it is, not as an echo of the past. In contrast, the therapeutic task for Jesse was more challenging. Namely, he did not have the successful life experiences Howard and Brittany could use in order to shift their thinking. He had limited emotional and family resources.   Furthermore, the changes needed to help him were not going to be mainly internal changes as we saw with Howard and Brittany. Jesse actually had to overcome inertia, avoidance, and fear and start going to school. In school, he would need a more positive set of experiences so that he would experience positive reinforcement for going rather than negative reinforcement for staying home. Also, both of his parents would need to learn more effective strategies for managing the situation.

And they did. While Jesse participated in a program of reprocessing his fears, Mother was willing tobully pic 7 participate in a graduated program in which Jesse dressed for school and she drove him to the school, then home, without going in. When his anxiety at that subsided, she could escort him to the door, then home. After a few days of that, she escorted him through the hallway to the office. Later, she stood by the office and watched him walk through the hall on his own, even when other kids were present. Meanwhile, we reprocessed the fear of walking into a classroom and rehearsed going into class. Eventually, Jesse managed to go and to sit through a class. He used some tools we had discussed and practiced, including some 3 X 5 cards on which we wrote statements to help him cope, such as, “I can sit quietly. After one minute, when I look around, I see no one is paying attention to me.” “My prime job is listening to the teacher.” The following September, Jesse was going to school full days. We had rehearsed strategies for having his parents interrupt any negative interactions with his brother, and family life became more pleasant for everyone in the home.

As a psychotherapist, I come into the picture after the damage has been profound. The treatment approach is to desensitize memories and experiences of teasing and bullying, overcome avoidance, increase skills to manage the situation, shift thinking from victimhood and defectiveness to assertiveness and adequacy, re-design family interactions, and enlist supports from school personnel. In a follow-up essay, we will discuss some ways for parents to work with children to prevent or stop teasing and bullying before damage occurs, before psychotherapy may be required.

*Reference for the Schulman story:

*Note: The names and details of the stories of Howard, Brittany, and Jesse have been altered in order to substantially disguise the identities of real individuals.

Post Traumatic Stress Disorder

PTSDPosttraumatic Stress Disorder (PTSD) is a reaction which often occurs when a person has been exposed to extreme stress, trauma, or painful experiences. In other words, the person has experienced or witnessed actual or threatened bodily injury or some other extreme situation.
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Psychotherapist / Counselor – In Home or Outpatient Therapist Shorehaven Behavioral Health, Inc – Milwaukee, WI

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EMDR: Eye Movement Desensitization and Reprocessing

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Brochure on EMDR

Did you know that most emotional problems derive from earlier life experiences? EMDR is a complex method that can assist in bringing about changes in how the nervous system processes experiences. To learn more about EMDR, please read our brochure, which can be accessed by clicking on the link above. 

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