Providentia

Play Therapy for Children in Crisis

A recent article published in the International Journal of Play Therapy reviewed the literature regarding the use of child-centered play therapy with children who have experienced natural disasters and catastrophic events over the last 11 years. The frequency of natural disasters has increased over the last decade. Tsunamis, tornadoes, earthquakes, and hurricanes have ravaged towns, cities, and countries, leaving thousands dead. Beyond the physical injuries suffered, the survivors of these catastrophes, many of them children, often suffer emotional devastation, and profound losses of routines, friends and family, and a sense of security. Child-centered play therapy empowers children as they lead the play session with a trained adult, assisting them on their journey. This therapy modality allows the child to be in control, which is paramount for those having experienced natural disasters where they were completely helpless. The child may then begin to heal as they make sense of their trauma through their natural language of play. This article provides literature review supporting a case for child-centered play therapy for children experiencing natural disasters as well as recommendations for future research in this area.

For the abstract

January is Alzheimer Awareness Month

The Alzheimer Society of Canada has announced that January is Alzheimer Awareness Month as part of a nationwide campaign to provide information for people who may be living undiagnosed or who are afraid of developing the disease.    Alzheimer's disease is the most common form of dementia and most often diagnosed in people over sixty-five years of age.   Though there are many common symptoms, most cases of Alzheimer's develop differently in each individual and almost half of all Canadians with dementia wait too long to be diagnosed.    While there is no cure, delayed diagnosis can mean losing valuable time in receiving treatment which can delay the onset of more serious symptoms.

There are numerous warning signs of potential Alzheimer's disease although many people ignore these signs which can often be mistaken for problems relating to stress, depression, or simple aging.   These signs can include:

• Memory loss affecting daily functioning - along with forgetting dates and other important information, people can also have trouble absorbing new information
• Difficulty performing familiar tasks - forgetting how to do things you have been doing your entire life
• Problems with language - forgetting words, misusing words, or having difficulty following conversations (not to be confused with problems due to hearing loss)
• Disorientation in time and place - getting lost in familiar places or not knowing the right day or date
• Impaired judgment - Dressing inappropriately or making serious errors in tasks such as driving or preparing meals
• Problems with abstract thinking - Not understanding concepts that were once familiar, how to use a calendar for example
• Misplacing things - Not just forgetting where you left your keys but consistently doing things like leaving your watch in the freezer
• Changes in mood and behaviour -  This can include severe mood swings and angry outbursts
• Changes in personality - Behaving out of character, etc.  feeling paranoid
• Loss of initiative - Losing interest in doing many of the things you used to enjoy doing previously

Though many people experiencing these warning signs may feel frightened at what they could mean, proper diagnosis should only be left up to a qualified professional after careful testing.    There can be different reasons for why these problems are occurring and prompt diagnosis and treatment can be essential in helping people cope.    Even for progressive diseases such as Alzheimer's, there are treaments that can help people live active and productive lives as long as possible. 

As serious as Alzheimer's disease and other dementias are today, the number of new cases is expected to rise dramatically over the next few decades as more baby boomers develop symptoms.    In Canada alone, the health care costs to deal with dementia will likely rise from $33 billion dollars today to $293 billion dollars by 2030.  

So see your doctor if you are an older adult who is experiencing some of the warning signs.   Don't be afraid to ask questions or to request a referral.   Use this checklist to describe your concerns and ask a family member to go with you for emotional support and to help your doctor understand your concerns.

Four Decades in Hospital For Necklace Thief

When Franklin H. Frye was found not guilty by reason of insanity for stealing a necklace worth only $20 in 1971, nobody suspected that his incarceration would last more than forty years.   Or that he would become the centre of a legal battle exposing serious flaws in the laws surrounding mental health sentences.  

Still housed in the psychiatric wing of St. Elizabeth's Hospital in Washington, D.C., the 70-year-old Frye's repeated attempts at being released over the past four decades have failed to allow him to leave the hospital permanently. 

To read more, check out my new Psychology Today blog post.

Why Smoking "Skunk" Cannabis May Lead to Early Psychosis

A recent study published in Schizophrenia Bulletin suggests that daily use of high-potency cannabis can lead to chronic users experiencing their first psychotic episode earlier than they otherwise would. A team of researchers led by Dr. Maria Di Forti at the Institute of Psychiatry at King's College in London surveyed 410 patients between the ages of 18 and 65, all of whom had a history of psychotic episodes. The survey examined history of drug, alcohol, and tobacco use as well as the age at which the patients first experienced a psychotic episode.

What the researchers found was that males were more likely to use cannabis overall than females and also experienced psychosis at a younger age. They also found that patients who started smoking cannabis at age 15 or younger preferred to smoke high-potency "skunk" cannabis rather than lower potency "hash" type cannabis. The earliest onset of psychotic episodes occurred in males who have been smoking high-potency cannabis on a daily basis -- on average, their first psychotic episode occurred six years earlier than for non-users.

Skunk cannabis has become increasingly popular in recent years with a THC content of 16 percent compared to the 4 per cent found in lower-potency "hash-type" cannabis. Though news reports have raised concerns about the dangers associated with skunk cannabis, including people being admitted to hospitals for mental health problems, skeptics have disputed the potential risks involved. Believed to have originated in the United States, European growers have developed a profitable business growing skunk cannabis in hothouses. Users often regard it as being safer than than regular marijuana because it is harder to fake but long-term use of skunk cannabis has been linked to adverse psychiatric effects including depression.

To read more, check out my new Huffington Post contribution

The Power of the Placebo (Part 1 of 2)

The Siege of Breda is one of the most graphic events of the Eighty Years War (also known as the Dutch War of Independence).    Under the orders of Spanish general Ambrogio Spinola, the walled city of Breda in what is now the Netherlands was besieged by the Spanish army for more than eleven months.   So extreme were conditions inside the town for the 7,000 soldiers defending the town that they soldiers began dying of scurvy due to the lack of fresh fruit and vegetables.   Though curable through simple nutrition, scurvy is potentially deadly for anyone whose diet is low in Vitamin C and the Dutch soldiers were no exception.   Along with problems stemming from malnutrition, the long siege also led to a critical shortage in various medications, including medications for relieving pain (primarily opium and laudanum).     To solve this problem,  the garrison commander Justin of Nassau (a son of William of Orange), hit on a cunning plan.

Working with the city's doctors,  Justin had the doctors provide their patients with a powerful new medicine that he reportedly managed to smuggle in from the mysterious East.   The medicine was so strong that only a few drops in a gallon of water would clear up their symptoms.    The soldiers were impressed that their commander had managed to get them this medicine despite the risks and expense involved.  Except that the "medicine" in this case was nothing more than a mixture of wormwood, camomile, and camphor, carefully placed into small phials which Justin provided to the doctors.  While available reports stated that "they took the medicine eagerly and grew well rapidly", there are likely limits to how well the power of suggestion could work in preventing the symptoms of scurvy.   Certainly men continued to die and only 3,500 Dutch soldiers were still alive by the time Justin surrendered the town.  

Though medical doctors had long observed that patient belief had a powerful effect on the body and how they responded to medical treatment, the first formal investigation into what would be called "the placebo effect" would not begin until the early 19th century.   The word "placebo" is Latin for "I will please" and actually comes from a Latin translation of the Bible.   British physician John Haygarth published what would be the first treatise on the placebo effect when he investigated that medical effectiveness of a popular cure of the time known as "Perkins tractors."   Invented by American physician Elisha Perkins, these "tractors" consisted of two 3-inch metal rods made of steel and brass.  By using the tractors to "draw off the noxious electrical fluid that lay at the root of suffering", Perkins claimed to be able to cure a wide variety of illnesses including rheumatism and arthritis.

Even though conventional medical doctors were quick to denounce Perkins' invention as sheer quackery, many patients reported getting significant pain relief from the treatments and John Haygarth decided to investigate further.    Alarmed at the growing popularity of Perkins tractors among his patients in Bath,  Haygarth dem0nstrated that patients could get the same pain relief from rods made of virtually any substance and that they were unable to tell the difference between fake tractors and the "real" ones.   He also noted that some patients actually got worse instead of better which suggested that imagination could cause as well as cure disease.    What mattered most was the credibility of the doctor (famous doctors were more likely to get positive results than obscure ones) as well as how credulous the patients were.    The best results appeared to come from both the doctor and the patient believing in the power of the medical treatment.    He prophetically commented that: "medical practitioners of good understanding, but of various dispositions of mind, feel different degrees of scepticism in the remedies they employ. One who possesses, with discernment, the largest portion of medical faith, will be undoubtedly of greatest benefit to his patients."

As Haygarth concluded in his 1800 paper Of the Imagination as a Cause and as a Cure of Disorders of the Body,  what really caused pain relief was the belief that patients were getting an apparently effective treatment.     Haygarth concluded in his paper that his results showed "to a degree which has never been suspected, what powerful influence upon diseases is produced by mere imagination".     While his research into the power of  belief would be largely overlooked by medical historians (he is mainly remembered as a pioneer in smallpox inoculation),  he is still the first physician to raise questions about the placebo effect which have haunted discussions of alternative medical treatments ever since.  

At the same time that John Haygarth was making his groundbreaking observations on the power of positive belief in relieving pain, the influence of Franz Mesmer and his disciples was also being felt across Europe and North America.   Despite attempts by skeptics such as Benjamin Franklin and Antoine Lavoisier to debunk Mesmer's work, mesmerists would ply their trade for decades afterward and physicians were slowly beginning to understand how they were accomplishing their apparently miraculous cures.   

Along with mesmerism, the early 19th century was also seeing a rise of interest in homeopathy.    Based on the "like cures like" doctrine of Samuel Hahnemann, homeopathic practitioners began offering their treatments for various illnesses with only anecdotal evidence from satisfied patients to prove that it even worked.    The first formal clinical trial to test the effectiveness of homeopathic medicine was carried out in Russia in 1832.   Not coincidentally, it was also the first clinical trial to use a placebo in medical research.   Tests comparing homeopathic medicine with placebo pills made of flour paste showed no real difference was found in medical effectiveness.     After publishing these results, the term "placebo effect" became well-known to medical researchers across Europe and North America (though homeopathic medicine seems not to have been seriously derailed by the findings).

In another informal test of the placebo effect, French physician Albert Matthieu informed many of his tuberculosis patients at the Hopital Andral in Paris of a powerful new treatment for tuberculosis that had recently been discovered in Germany.   This new treatment, which he dubbed "antiphymose" was supposed to yield wonderful results in people suffering from tuberculosis and the news quickly spread with patients demanding that the drug be tested on them.   After a time, Matthieu began conducting clinical trials which the drug he had supposedly received from Germany.   All patients receiving antiphymose injections were carefully tested on a regular basis to see if their weight and temperature changed as a result of the new treatment. 

According to the results, antiphymose had a powerful effect on tuberculosis patients receiving the injections.   Not only did the patients gain weight but their chronic fever was reduced as well.  Some gained as much as three kilogrammes of weight while other symptoms such as persistent coughing and insomnia improved as well.    When the antiphymose injections stopped, the old symptoms returned as well and patients quickly lost the weight they had gained before.    Only afterward did Matthieu reveal that there was no such treatment as antiphymose.   What they had received was simply sterilized water and saline.   The record fails to state how the patients responded to being deceived, even in a good cause.

Continue to Part 2

 

Child Maltreatment and Foster Care

Children with a history of maltreatment and placement into foster care face elevated risks of poor psychosocial outcomes including school failure, substance use, externalizing, and deviant peer association. For children in the general population, school engagement appears to be a promotive factor in preventing negative outcomes. In a study published in Developmental Psychology, differences in 3 dimensions of school engagement (behavioral, affective, and cognitive) in early elementary school were explored in maltreated children in foster care (n = 93) and a community comparison group of low-socioeconomic status, nonmaltreated children (n = 54). It was also hypothesized that these 3 dimensions of school engagement would mediate the association between being maltreated and in foster care and several outcomes in late elementary school (Grades 3–5): academic competence, endorsement of substance use, externalizing behaviors, and deviant peer association. Measures were multimethod and multi-informant. Results showed that the children in foster care had lower affective and cognitive school engagement than children in the community comparison group. Structural equation modeling revealed that both affective and cognitive school engagement mediated the association between group status and academic competence in late elementary school. Cognitive engagement also mediated the association between group status and engagement in risk behaviors. The identification of dimensions of early school engagement that predict later outcomes suggests potential points of intervention to change trajectories of academic and behavioral adjustment for maltreated children in foster care.

For the abstract

New York Disability Scam Exposed

More than 100 indictments were handed down on January 7 in a Manhattan courthouse relating to a disability fraud ring that received an estimated $21 million dollars in benefits from a federal disability program.   In filing the indictments, Manhattan District Attorney Cyrus Vance stated that many of the retirees named had claimed posttraumatic stress disorder and depression relating to the terrorist attacks of September 11, 2001.  

The accused include more than 72 retired city police officers, eight firefighters, four correctional officers, and a Nassau County police officer.    Others are suspected of being involved as Vance suggests that hundreds of others may have filed false claims as well.   Many ex-officers collected years of benefits for psychiatric disorders which supposedly left them unable to work.   While many claimants had legitimate physical problems, they were often coached to magnify their symptoms to qualify for federal Social Security disability insurance. 

In a statement released to the press, Vance reported that participants in the scheme "cynically manufactured" mental illness claims.   “For years, federal taxpayers unwittingly financed the lifestyles of the defendants charged today,” he said in his statement and that the people involved dishonoured the legitimate first responders who did serve their city at the expense of their own health and safety.   

From January 1998 to December 2013, the four ringleaders of the disability scheme earned tens of thousands of dollars in kickbacks by coaching claimants on how to falsely describe symptoms of depression and other mental disorders.   One of the ringleaders, 81-year-old Raymond Lavallee is a former FBI agent and retired head of the rackets bureau at the Nassau County District Attorney's office.    Lavallee and the other three primary dependents are charged with grand larceny in the first and second degree as well as attempted grand larceny in the second degree.    Other people named in the indictments have been charged with attempted grand larceny in the second degree

Investigators found that many of the claimants who had filed disability claims often held jobs despite their claims of being completely disabled.   Claimants often reported symptoms of depression, anxiety, and posttraumatic flashbacks whic made them unable to do any kind of work despite their holding down jobs.   Many who denied being able to operate a computer had Facebook pages and Twitter handles and maintained an active online presence.    With what Vance described as "shocking brazenness",   claimants often made little effort at concealing their fraud despite some receiving hundreds of thousands of dollars in disability claims.

The indictments handed down by Vance are likely to take years to resolve.   Arraignments have already begun for the dozens charged with several people already pleading guilty and being released without bail.   Attorneys for the accused have already blamed the flawed disability claims system for many of the problems involved in requiring proof of complete disability before allowing claimants to receive compensation.   The fact that many of the claimants also have legitimate injuries will probably complicate what is already proving to be a nightmarish case to resolve for the legal system and the federal agencies involved.

For more information

When A Therapist is Being Stalked

Based on victim surveys, about 16 percent of women and 5 percent of men in the United States reported having been stalked at some point in their lives.     The legal definition varies, stalking is usually defined as "repeated unwanted behaviors that reasonably cause the individual who is being stalked to experience fear of harm or death to self, family, or household" but many stalkers are careful enough to avoid breaking laws.   Even though the majority of stalkers are men, an estimated 12 to 22 percent are women although the motivation often varies according to the intended target.

According to the research of Paul E. Mullen and his colleagues, there are five types of stalkers though there can be considerable overlap among the different categories.  

• Rejected stalkers who are seeking revenge following a perceived rejection (real or imagined)
• Intimacy-seeking stalkers who are seeking to form a close relationship with their intended target
• Incompetent stalkers lack basic social skills and often engage in stalking behaviour in the hope of becoming intimate with their target
• Resentful stalkers are revenge-seekers who feel they have been somehow wronged by their target.   They are often prone to paranoid ideation that is difficult to treat.
• Predatory stalkers seek power and control over their targets and are most likely to intimidate their their victims.   These are the stalkers most likely to be charged for their offenses.

While most stalkers are not violent, the risk should not be overlooked despite the reluctance of many police officers to lay charges unless a clear criminal act occurs.   Risk of violence usually rises in stalkers with a previous criminal history while nonpsychotic stalkers are more likely to become violent than psychotic stalkers.    Still, regardless of the actual risk of assault, stalking has a clear impact on the mental health of their targets.   Around twenty to thirty percent of stalking victims seek counseling because of the emotional distress caused by stalking and one in seven will change their residence.   Stalking victims are also much more likely to arm themselves or take other defensive measures to ensure their safety. 

But what if the stalking victim is a mental health professional?  Being stalked by a former patient is a potential threat for many therapists with several studies of mental health settings in the United States suggesting that as many as six to eleven percent of therapists will be stalked by patients at some point in their careers.    Studies of different medical specialties suggests that psychiatrists are the most likely to be stalked with one Australian study showing the incidence of psychiatrists being stalked is as high as 19.5 percent.  

To read more, check out my new Psychology Today blog post. 

 

 

 

 

Babe and Dickie on Trial (Part 3 of 3)

Continued from Part 2

William White was particularly effective in his testimony since he essentially provided the judge (and the reporters covering the trial) with a jargon-free introduction to Freudian theory.   A gifted lecturer, Dr. White had ample experience with presenting psychoanalytic ideas to a skeptical public and explained many of the concepts in his testimony in a story-like manner that went over well in the courtroom.   In discussing Richard Loeb's fantasy life, for example, White described his longstanding criminal fantasies and that he "wanted to commit a crime that would be perfect, that would be thoroughly and completely planned in all details, that would baffle the police, that would be an object of great concern in the immediate community, that would leave no clues, that would an intellectual feat to accomplish."    He also described Loeb as "going in the direction of a split personality" because of the inner confliict  between his intelligence and his "infantile emotional make-up."

The testimony about Nathan Leopold focused on the abnormal relationship he had as a child with a governess identified only as "Sweetie".   Not only did "Sweetie" dominate him completely, even more than his own parents, but Leopold had his first sexual experience with her before he was ten years old.     According to White's testimony, Leopold was completely dominated by Richard Loeb and he suggested that Leopold would never have committed any crime without Loeb's criminal fantasies to spur him on.  At the same time, Loeb might never have acted on his own fantasies without Leopold's help.   As far as White was concerned, it was the mutually reinforcing relationship between the two of them that made them commit murder

Still, William White made two unfortunate comments in his testimony that were used against him.   At one point, he described Richard Loeb as "a little child talking to his Teddy bear."   He also used two childhood pictures of Loeb dressed as a cowboy and a policeman, complete with toy gun, to suggest that the pictures show Loeb's longstanding antisocial tendencies.    White's testimony was openly mocked by the prosecutor, Richard Crowe, and in newspaper editorials across the country.     They openly suggested that White had been fooled by a "fabric of lies" told by Loeb and Leopold.     The fact that White was being paid $250 a day for his testimony (a huge sum in those days) raised suggestions that he was little more than a "hired gun" whose testimony had been paid for by the Loeb and Leopold families. 

Even with the open skepticism about White's testimony however, the public was still fascinated with the "new psychology" being presented by White and the other psychoanalysts.   Despite merciless cross-examination, which often made White and his colleagues look foolish,  the image of the defendants being mentally unbalanced still swayed public opinion.    The lurid details of the testimony, some of which was declared to be "too scandalous" for women and had to be whispered in the courtroom,  suggested that Loeb and Leopold were guilty of "perversion"  (a.k.a., homosexual acts) which helped shape their antisocial fantasies.    One psychiatrist even focused on the physical abnormalities he found in the defendants.   Nathan Leopold, for example, had a "diseased" thyroid gland and  problems with his adrenal glands (among other things) and concluded that his sex  glands were "overfunctioning".

The final defense expert, Dr. Bernard Glueck, gave even more explosive testimony.   Along with suggesting that Loeb had a "split personality", he also reported that Loeb admitted to the actual killing with a chisel blow to the head.  As for Leopold, Glueck described him as having a paranoid obsession with Dickie Loeb and fantasizing about being his slave.   Friends and family members gave testimony essentially supporting many of the conclusions raised by the psychoanalysts (and were promptly accused by the prosecution of lying to protect the defendants). 

When Clarence Darrow and the other defense attorneys rested their case on August 12,  the alienist testimony was enough to generate the reasonable doubt that Darrow had intended.  Though newspaper editorials were still scathing, there was already considerable support for the psychoanalytic argument in the public mind.   Because of the riveting testimony reported in newspapers, Freudian psychoanalysis had truly arrived in the United States.  

While the prosecution experts attempted to shake the psychoanalytic testimony, none of them were psychoanalysts and Darrow challenged the very legal definition of insanity in his cross-examination.   By the time the prosecution rested its case on August 19, the battle of the alienists was over.   The closing statement that Clarence Darrow made is still considered one of the great classics in legal history.   Not only did Darrow weigh in with his own personal opposition to the death penalty, but his conviction that the crime committed by his clients was shaped by their abnormal upbringing and their own diseased fantasies.   It was a powerful speech that mesmerized the courtroom and left many people in tears.   His closing statement was reprinted in courtrooms across the country and cemented Darrow's reputation as a gifted lawyer and social crusader.

As for the prosecutor, his closing argument was succinct and sarcastic at times, especially concerning the expert witnesses whom he described as the "Three Wise Men from the East."    He heaped ridicule on William White and the other psychoanalysts and also suggested that Loeb and Leopold "deserved the same mercy as coiled snakes waiting to strike."  After that, the fate of the two defendants was left up to Judge Caverley.

On September 10, 1924,  Nathan Leopold and Richard Loeb were sentenced to life imprisonment for murder with an additional 99 years each for the kidnapping of Bobby Franks.   In explaining his reasoning for not handing down the death penalty, Judge Caverley stated that:  "In choosing imprisonment instead of death the court is moved chiefly by the consideration of the age of the defendants, boys of 18 and 19 years."   He also acknowledged the role that the alienist evidence played in the sentencing but concluded that "it is beyond the province of this court, as it is beyond the capacity of human science in its present state of development, to predicate ultimate responsibility for human acts."

Not surprisingly,  numerous newspaper editorials trumpted their own opinion of Judge Caverley's controversial decision.   The fact that other defendants as young as Loeb and Leopold would continue to get the death penalty across the United States was conveniently overlooked.   The main issue for most newspapers was whether the New Psychology (as it was often called) should be used in the courtroom to mitigate sentences.  

As for Nathan Leopold and Richard Loeb, they were both sentenced to Joliet Prison and managed to continue their relationship and even taught classes together in prison.     Richard Loeb was attacked and killed by a fellow prisoner on January 28, 1936.    His assailant claimed that Loeb had tried to sexually assault him and the prison officials ruled in his favour despite the obvious inconsistencies in his story.    Nathan Leopold was eventually paroled in 1958 and wrote a book on his experiences, Life Plus 99 Years.     He later moved to Puerto Rico and married a widowed florist.    Leopold also wrote a well-known book on Puerto Rican birdlife and managed to stay out of the public eye for the most part before dying in 1971.

Along with the impact the Loeb and Leopold trial had on the history of law, it also had a powerful impact on popular culture including inspiring several movies and plays.   One of these, Compulsion, which came out in 1959, was unsuccessfully challenged by Nathan Leopold who accused the movie's producers of trying to exploit his life story.    Other films, including Alfred Hitchcock's 1948 film, Rope, are still considered movie classics. 

But the greatest impact of the Loeb and Leopold case on popular culture is likely the role that it played introducing Freudian psychoanalysis to mainstream society.  Newspaper coverage of the Crime of the Century and the court case did more to popularize Freud's ideas than another case before or since.   While most people today are unaware of the Loeb and Leopold trial except through movies such as Rope and Compulsion, the graphic news coverage that made Freudian terms into household words has been largely forgotten except for history buffs.   

Still, because of what happened in that fateful summer of 1924, psychiatric and psychological testimony in the courtroom would never be the same again.

 

 

 

 

Studying Hypnagogic Hallucinations

A recent study published in Dreaming represents an attempt, in the context of the following questions, to examine the hypnagogic hallucinations experienced by one person over several years: (a) Do the hallucinations occur randomly, or follow some kind of trend or pattern? (b) Can the content of the hypnagogic experiences be categorized in types, and how do these relate to existing literature? (c) How do these types change or develop across the years? To find answers to the questions posed, first, the period of time was measured between consequent diary entries. Second, the actual material recorded by the dreamer was assessed using 14 criteria. These assessments were then subject to a P-Technique Factor Analysis. The Factor Analysis extracted four significant factors, labeled “Unusual Bodily Experiences,” “The Intruder,” “Incubus,” and “Fear.” The extracted Factors are well supported by the results of similar studies dealing with random samples. Theoretical implications and consequences of the practical work will be discussed. The present investigation was inspired by the fact that much of the existing research into the topic is based on cross-sectional studies, which are inherently unable to account for individual temporal development in the hypnagogic phenomena in question.

For the abstract