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The Brain’s Drugstore: The Relationship Between
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Psychotherapy 36 Annals of
& Integrative Health
fa l l / w i n t e r 2 0 1 1 • Vo l u m e 1 4 , N u m b e r 3
on the cover how far have we come 18 conference wrap up 30 grand master yang 36 the brain’s drugstore 52 milk thistle 46 guided meditation 56
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2011 Executive summit Wrap-UP | 2012 executive summit
30 Departments
w w w. t h e e x e c u t i v e s u m m i t. n e t / a n n a l s
Features 18 How Far Have We Come
in Understanding Obsessive-Compulsive Disorder in Children and Adolescents? By Karin Tochkov, PhD
52 The Brain’s Drugstore by Sara Rendell and Michael Anch, PhD
78 Internet Defamation: Defending Your Name by Josh Roberts
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Annals of Psychotherapy & Integrative Health
08 mind news 34 new members 51 short story
By James McAdams
70 book reviews 76 CE test pages
08 www.americanpsychotherapy.com
Integrative Health 35
36 The Art of Tai Chi by Trysta Herzog
columns
46 Natural Remedies
52
Milk Thistle NCCAM clearinghouse
48 guided meditation for First Thing in the Morning and Coming Home
12 chair’s corner: Walkin’ and Talkin’
By Eve Eliot
By Daniel J. Reidenberg, PsyD, FAPA, BCPC, MTAPA
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16 culture notes:
Pills, Pills, & More Pills By Irene Rosenberg Javors, LMHC, MEd, DAPA
52 Chaplain’s Column: The Purpose of Ritual
by Chaplain David J. Fair, PhD, CHS-V, CMC
68 Practice Management:
In the Health Care Reform Movement, What is Moving Us? By Ronald Hixson, PhD, LPC, LMFT, BCPC
78 chaplain’s brief:
Workplace Prayer Rooms
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Psychotherapy Annals of
& Integrative Health
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Gary Kesling, PhD, FAAMA, FAAETS C.G. Kledaras, PhD, ACSW, LCSW Michael W. Krumper, LCSW, DAPA Ryan LaMothe, PhD Allen Lebovits, PhD P. K. Frederick Low, MAppPsy, MSc, BSocSc, DAPA Edward Mackey, PhD, CRNA, MS, CBT Frank Malone, PsyD, LMHC, LPC, FAPA Beth McEvoy-Rumbo, PhD Thomas C. Merriman, EdD, SBEC (Virginia) Ginger Arvan Metcalf, MS, RN Yvonne Alleen Moore, MC, BCPC William Mosier, EdD, PA-C Natalie H. Newton, PhD, DAPA Kim Nimon, PhD Donald P. Owens, Jr., PhD Thomas J. Pallardy, PsyD, BCPC, LCPC, CADC Larry H. Pastor, MD, FAPA Richard Ponton, PhD Joel G. Prather, PhD, MS, BCPC, Helen Diann Pratt, PhD Ahmed Rady, MD, BCPC, FAPA, DABMPP Daniel J. Reidenberg, PsyD, FAPA, CRS Arnold Robbins, MD, FAPA Arlin Roy, MSW, LCSW Maria Saxionis, LICSW, LADC-I, CCBT, CRFT Alan D. Schmetzer, MD, FAPA, MTAPA Paul Schweinler, MDiv, MA, LMHC, DAPA Bridget Hollis Staten, PhD, CRC, MS, MA Suzann Steadman, PsyD Ralph Steele, BCPC Moonhawk River Stone, MS, LMHC Mary Elise Taggart, LPC Patrick Odell Thornton, PhD Mary A.Travis, PhD, EdS, MA, BS Charles Ukaoma, PsyD, PhD, BCPC, DAPA Lawrence M.Ventline, DMin Angela von Hayek, PhD, LMFT, LPC Gene W. Walters, DSW, LCSW Melinda Lee Wood, LCSW, DAPA Rosemarie Zlotnick Cecilia Zuniga, PhD, BCPC
Annals of Psychotherapy & Integrative Health (ISSN 1535-4075) is published quarterly by the American Psychotherapy Association. Annual membership for a year in the American Psychotherapy Association is $165. The views expressed in Annals of Psychotherapy & Integrative Health are those of the authors and may not reflect the official policies of the American Psychotherapy Association. Abstracts of articles published in Annals of Psychotherapy & Integrative Health appear in e-psyche, Cambridge Scientific Database, PsycINFO, InfoTrac, Primary Source Microfilm, Gale Group Publishing’s InfoTrac Database, Galenet, and other research products published by the Gale Group. Contact us: Publication, editorial, and advertising offices at 2750 E. Sunshine St., Springfield, MO 65804. Phone: (417) 823-0173, Fax: (417) 823-9959, E-mail: editor@americanpsychotherapy.com. Postmaster: Send address changes to American Psychotherapy Association, 2750 E. Sunshine St., Springfield, MO 65804. © Copyright 2011 by the American Psychotherapy Association. All rights reserved. No part of this work may be distributed or otherwise used without the expressed written consent of the American Psychotherapy Association.
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CONTINUING EDUCATION The American Psychotherapy Association’s sister organization, American College of Forensic Examiners International (ACFEI), provides continuing education credits for accountants, nurses, physicians, dentists, psychologists, psychiatrists, counselors, social workers, and marriage and family therapists. ACFEI is an approved provider of continuing education by the following: Accreditation Council for Continuing Medical Education National Association of State Boards of Accountancy National Board for Certified Counselors California Board of Registered Nursing American Psychological Association California Board of Behavioral Sciences Association of Social Work Boards American Dental Association (ADA CERP) Diplomate status with the American Psychotherapy Association is recognized by the National Certification Commission. For more information on recognitions and approvals, please visit www.americanpsychotherapy.com
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Mind News
If You Don’t Snooze,
Do You Lose?
Wake-Sleep Patterns Affect Brain Synapses During Adolescence An ongoing lack of sleep during adolescence could lead to more than dragging, foggy teens, a University of Wisconsin-Madison study suggests. Researchers have found that short-term sleep restriction in adolescent mice prevented the balanced growth and depletion of brain synapses, connections between nerve cells where communication occurs. “Adolescence is a sensitive period of development during which the brain changes dramatically,” Cirelli says. “There is a massive remodeling of nerve circuits, with many new synapses formed and then eliminated.” Cirelli and colleagues wanted to see how alterations to the sleep-wake cycle affected the anatomy of the developing adolescent brain. Using a two-photon microscope, researchers indirectly followed the growth and retraction of synapses by counting dendritic spines, the elongated structures that contain synapses and thus allow brain cells to receive impulses from other brain cells. They compared adolescent mice that for eight to 10 hours were spontaneously awake, allowed to sleep or forced to stay awake. The live images showed that being asleep or awake made a difference in the dynamic adolescent mouse brain: the overall density of dendritic spines fell during sleep and rose during spontaneous or forced wakefulness.
Spiritual Retreat
Can Lower Depression, Raise Hope in Heart Patients Attending a non-denominational spiritual retreat can help patients with severe heart trouble feel less depressed and more hopeful about the future, a University of Michigan Health System study has found. Heart patients who participated in a fourday retreat that included techniques such as meditation, guided imagery, drumming, journal writing, and outdoor activities saw immediate improvement in tests measuring depression and hopefulness. Those improvements persisted at three-and six-month follow-up measurements. The study was the first randomized clinical trial to demonstrate an intervention that raises hope in patients with acute coronary syndrome, a condition that includes chest pain and heart attack. Previous research has shown that hope and its opposite, hopelessness, have an impact on how patients face uncertain futures. “The study shows that a spiritual retreat like the Medicine for the Earth program can jumpstart and help to maintain a return to psycho-spiritual well-being,” says study lead author Sara Warber, M.D., associate professor of family medicine at the U-M Medical School and director of U-M’s Integrative Medicine program. “These types of interventions may be of particular interest to patients who do not want to take antidepressants for the depression symptoms that often accompany coronary heart disease and heart attack.”
The experiments are under way, but Cirelli can’t predict the outcome. “It could be that the changes are benign, temporary, and reversible,” she says, “or there could be lasting consequences for brain maturation and functioning.” University of Wisconsin-Madison (2011, Oct 10). If you don’t snooze do you lose? Wake-sleep patterns affect brain synapses during adolescence. ScienceDaily. Retrieved from http://www. sciencedaily.com/releases/2011/10/111009140219.htm
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The findings were published in the July issue of Explore: the Journal of Science and Healing.
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Parental Weight
Strongly Influences Thinness in Children
Media Habits of Young People May Make Them Drink More;
What Should Be Done? Media companies are increasingly targeting adolescents with TV shows that feature violence, alcohol and drugs. An interdisciplinary research project with researchers from the University of Gothenburg, Sweden, and colleagues from the UK is looking closer at how society and others should react to the link between young people’s media habits and their alcohol consumption. The project, called Alcopop TV Culture, is funded by the European Commission’s Daphne III program. It sets out to study the relationship between adolescent (age 10-25) media habits and alcohol consumption. A central issue is how the responsibility for increased adolescent drinking should be shared among different parties, such as state authorities, the alcohol industry, families and the adolescents themselves. The goal of the project is to develop a draft policy on how to allocate shared responsibility for use across Europe. This is not an easy task. The explosive growth of the global media landscape (internet, social media, etc.) implies that potential tools such as age limits and airtime regulations are becoming increasingly difficult to implement. ‘It is pretty clear that adolescents often feel belittled, for example, by societal campaigns and organizations that come to talk to them about
Children with thinner parents are three times more likely to be thin than children whose parents are overweight, according to a new study by UCL researchers. The study, published October 3 in the Archives of Pediatrics & Adolescent Medicine, shows strong familial influence on pediatric thinness. It was based on results from the Health Survey for England, in which data are collected annually from multiple households. From 2001 to 2006, trained interviewers recorded the heights and weights of parents and up to two children in 7,000 families, and used this information to calculate their BMI. The results showed a strong association between children’s and parents’ body size. When both parents were in the thinner half of the healthy-weight range, the chance of the child being thin was 16.2%, compared with 7.8% when both parents were in the upper half of the healthy weight range, 5.3% with two overweight parents, and only 2.5% for children with two obese parents. Professor Jane Wardle, UCL Epidemiology & Public Health, added: “Parents are often concerned if their child is thin, but it may just be their ‘skinny genes’. All genes have two versions, called alleles. We might think of weight-related genes as having a ‘skinny’ and ‘curvy’ allele. Thinner parents are likely to have more of the skinny alleles, increasing the chance of passing them on to their children. A child who inherits more of the skinny alleles from their parents will be naturally thinner.” Cancer Research UK (2011, Oct 4). Parental weight strongly influences thinness in children. ScienceDaily. Retrieved from http://www. sciencedaily.com/releases/2011/10/111003161933. htm
alcohol. This is one reason why we have a Facebook and a Twitter page full of new research reports, news and debates. We hope that the adolescents will use the page to gain information and to share their opinions,’ says Munthe. University of Gothenburg (2011, Oct 10). Media habits of young people may make them drink more; what should be done? ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2011/10/111010075458.htm
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Mind News
Green Tea is Effective in Treating
Genetic Disorder and Types of Tumors, Study Suggests A compound found in green tea shows great promise for the development of drugs to treat two types of tumors and a deadly congenital disease. The discovery is the result of research led by principal investigator, Dr. Thomas Smith at The Donald Danforth Plant Science Center and his colleagues at The Children’s Hospital of Philadelphia. Using atomic structures to understand the differences between animals and plants, Dr. Smith and his colleagues discovered that two compounds found naturally in green tea are able to compensate for this genetic disorder by turning off GDH in isolation and when the green tea compounds were administered orally. The Smith lab also used X-ray crystallography to determine the atomic structure of these green tea compounds
bound
to the enzyme. With this atomic information, they hope to be able to modify these natural compounds to design and develop better drugs. Their findings were recently published in The Journal of Biological Chemistry.
Increased Use of Bikes for Commuting Offers Economic, Health Benefits Cutting out short auto trips and replacing them with mass transit and active transport would yield major health benefits, according to a study just published in the scientific journal Environmental Health Perspectives. The biggest health benefit was due to replacing half of the short trips with bicycle trips during the warmest six months of the year, saving about $3.8 billion per year from avoided mortality and reduced health care costs for conditions like obesity and heart disease. The report calculated that these measures would save an estimated $7 billion, including 1,100 lives each year from improved air quality and increased physical fitness. “Moving five-mile round trips from cars to bikes is a win-win situation that is often ignored in discussions of transportation alternatives,” says Jonathan Patz, director of the Global Health Institute at the University of Wisconsin-Madison. “We talk about the cost of changing energy systems, the cost of alternative fuels, but we seldom talk about this kind of benefit,” he says. By lessening the use of fossil fuels, a reduction in auto usage also benefits the climate, Patz adds. “Transportation accounts for one-third of greenhouse gas emissions, so if we can swap bikes for cars, we gain in fitness, local air quality, a reduction in greenhouse gases, and the personal economic benefits of biking rather than driving. It’s a four-way win,” he adds.
Donald Danforth Plant Science Center (2011, Aug 15). Green tea is effective in treating genetic disorder and types of tumors, study suggests. ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2011/08/110815113607.htm
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University of Wisconsin-Madison (2011, Nov 2). Increased use of bikes for commuting offers economic, health benefits. ScienceDaily. Retrieved from http://www.sciencedaily. com/releases/2011/11/111102082804.htm
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Friendship
Makes a Difference in Stress Regulation Social rejection can cause stress in preschoolers, adolescents, and adults. A new study has found that friendships serve as a buffer against the negative effects of classmates’ rejection. The study, conducted by researchers at Radboud University Nijmegen in the Netherlands, appears in the journal Child Development. It looked at almost 100 fourth graders to determine whether victimization and exclusion by peers were related to increases in cortisol, and whether friendships moderated this association. Children who were excluded by their classmates had elevated levels of cortisol at school, the study found. They also had a smaller decline in cortisol over the course of the day. Both of these findings may indicate that exclusion is stressful. This was even more pronounced for excluded kids who had few friends or had friendships that were characterized as low in quality. Society for Research in Child Development (2011, Oct 26). Friendship makes a difference in stress regulation. ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2011/10/111026091229.htm
Fatherhood
Joking, Pretending with Toddlers Gives Them Head Start in Life Skills
After men become fathers for the first time, they show significant decreases in crime, tobacco, and alcohol use, according to a new, 19-year study. “These decreases were in addition to the general tendency of boys to engage less in these types of behaviors as they approach and enter adulthood,” said David Kerr, assistant professor of psychology at Oregon State University and lead author of the study. “Controlling for the aging process, fatherhood was an independent factor in predicting decreases in crime, alcohol and tobacco use.” “This research suggests that fatherhood can be a transformative experience, even for men engaging in high risk behavior,” he said. “This presents a unique window of opportunity for intervention, because new fathers might be especially willing and ready to hear a more positive message and make behavioral changes.” The study was published in the current issue of the Journal of Marriage and Family. Collaborators included the Oregon Social Learning Center in Eugene, Ore., and the University of Houston.
Parents who joke and pretend with their toddlers are giving their children a head start in terms of life skills. Most parents are naturals at playing the fool with their kids, says a new research project funded by the Economic and Social Research Council (ESRC). However parents who feel they may need a little help in doing this can learn to develop these life skills with their tots. The study examined whether parents offer different cues such as tone or pitch of voice in order to help their toddlers understand and differentiate between joking and pretending. Findings reveal that parents rely on a range of language styles, sound and non-verbal cues. For example, when pretending, parents often talk slowly and loudly and repeat their actions. Conversely, parents tend to cue their children to jokes by showing their disbelief through language, and using a more excited tone of voice. “We found that most parents employ these different cues quite naturally to help their toddlers understand and differentiate these concepts,” researcher Dr. Elena Hoicka points out. “While not all parents feel confident in their natural abilities, the research does show that making the effort to interact in this way with toddlers is important. Knowing how to joke is great for making friends, dealing with stress, thinking creatively and learning to ‘think outside the box’. Pretending helps children learn about the world, interact with others, be creative and solve problems.”
Can Help Change a Man’s Bad Habits
Oregon State University (2011, Nov 8). Fatherhood can help change a man’s bad habits. ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2011/11/111107161800.htm
Economic and Social Research Council (2011, Oct 27). Joking, pretending with toddlers gives them head start in life skills. ScienceDaily. Retrieved from http://www.sciencedaily.com/releases/2011/10/111027112508.htm
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Chair’s Corner
Walkin’ and Talkin’: Caring one person at a time By: Daniel J. Reidenberg, PsyD, Fellow, American Psychotherapy Association, Board Certified Professional Counselor, Master Therapist
think back to high school and try to remember your principal. What was his/her name? What do you remember most about him/her? Did you ever have the chance to talk with this person (not about something that you were in trouble for)? I’m guessing most of us don’t even recall our high school principal, let alone anything significant about them and what they did for us. For the fewer of us that do remember, I’d suspect it was for something we might want to forget. I want to introduce you to the principal you wish you would have had. More than that, this principal is one you wish your children had. He has a lot to teach therapists everywhere about caring, one person at a time. Mike Farley, or Mr. Farley as most of his students know him, is the principal of a very large suburban high school. One of the largest districts in the Minnesota with over 28,000 students, Anoka High School sees 2,400 students pass through its doors each year, is diverse, leads in academics and sports, and is filled with pride. The school’s mascot, ironically, is a tornado and for the last two years Anoka High School has been through the storm of its life that has been weathered with the leadership of Mr. Farley. Mr. Farley is not the principal you remember and probably isn’t the typical principal buried in administrative paperwork, emails and meetings. Instead, he is out with his students. Present. Available. Interested in them, the good, the bad, and everything in between. When you run any business that has dozens of direct reports and employees you are bound for challenges. Rarely does everyone agree with your decisions. Less frequently are you seen as popular. 12
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Nonetheless you still lead and you still have followers. Your time is spent meeting competing demands of (in this case) union rules and regulations, your desires for results, meeting outcome measures, and making people happy. Imagine trying to do this every year and you now have a small sense of what Mr. Farley has to face each year as the student body changes. While you can plan for problems and challenges, you can never plan for everything, and two years ago Anoka High School and other schools in the district were in the direct path of a storm not of natural forces, but of multiple suicides. I was called in as a consultant by the district office after two students had taken their lives. My job was to help the district assess what might be happening, reduce the risk of contagion (a particularly significant problem for youth and in school settings), and get a message out to the faculty and students in the district that sui-
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already to them, he was insistent on learning everything he could about suicide, mental health, resiliency, self-esteem and positive behavior change. After consulting with experts, reading and researching best practices, and relying on his own experiences as a coach and parent, he set out to make a difference. He started by taking a simple “thumbs approach” to finding out where the students were. What did he mean by this? At any moment, in any location, he would ask his students for a thumbs assessment. Thumbs up meant they were ok or better. A thumb in the middle or pointing down meant there was cause for concern. Most often the kids would give him a thumbs-up, but occasionally it would be in the middle or down. If it was not up, Mr. Farley’s
What did he mean by this?
At any moment, in any location, he would ask his students for a thumbs assessment.
cide can be prevented. As planning and funding was sought to get everything ready to be implemented, additional suicides tragically occurred in the district. In the age of new technology, youth spread many messages about their friends who had died, some accurate, many not. By the time we were able to get things underway, 5 or 6 students had taken their life in a few months and contagion was apparent in this community. Suicide attempts and ideation were a regular occurrence for youth and hospital beds were filling with youth from this community who were deemed at risk of suicide. Local, regional and national media picked up on “the story” and to this date hasn’t let it go. I went to the schools and held debriefings for the faculty of each school. I arranged for speakers to talk to the youth and we conducted an in-service training for faculty, counselors, administration, etc. Feelings were intense in every school. Teachers were on edge, waiting for the next suicide to occur. People were “afraid to answer the phone” and hear “who died now.” Youth that I spoke with told me they felt that “school was becoming a place where people just killed themselves whenever they had a problem.” But one man, Mr. Farley, stood up and out and said no more: “I am not having this happen in my school again.” He felt that the school was like a family and, as a member of the family in the community, something needed to be done. Mr. Farley was clearly frustrated by what was happening. More than being frustrated, he was sad and concerned and he wanted this to stop. He also wanted his students to know that not only was school a safe place to be, but that people there cared about them. Yes, Mr. Farley set out to create an environment that was going to be a safety net for his students. Despite all that had happened (800) 592-1125
next intervention was what I believe has made the difference for the students as they lived through the storm. When Mr. Farley didn’t get a thumbs-up, he would walk right over to that student or call them over and ask them “What’s up? How are you doing?” It was really simple and clear, but what struck me most about this approach was what happened next. If the student was hesitant or reluctant in answering him, or they admitted things weren’t so great, at that moment he would say to them “C’mon, we’re walkin’ and we’re talkin.” And that was it. He didn’t just send them to someone else. He didn’t say to the student come see me after your next class. He didn’t tell them he had a meeting to go to and to stop by his office later. Instead what he did was say to them right here, right now, you are my priority and I’m listening to you. We’re spending time together and working on this problem, whatever it is, until you can give me a thumbs-up. If you ask Mr. Farley about this, he will tell you he was just doing what anyone else would do. He would tell you that this approach might not work for someone else, but for him it was all that he could do and he wasn’t going to give up on it. He would tell you that some of the students just didn’t have anyone at home that would do this and while he wasn’t their parent, he did care and he wanted them to know that someone in their life did. For real. For now. For whatever reason they needed them to. And Mr. Farley’s approach spread among the people who worked for him and throughout his building a sense of community grew. A pseudo, but real family who cared about everyone developed and going beyond what he ever envisioned, and it even spread to some of the students who started helping other students. His plan was working and the beauty of this was that he never really planned on it to turn out as it
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Chair’s Corner did. Rather, he did what he thought was right and made a difference. A lifesaving difference to many, all at the same time as maintaining a clear expectation that when they were in school they were there to learn. In the time since Mr. Farley began this approach there have not been any suicides in his school and after the storm that hit his community, this is something he can be proud of even though he never thought he was going into the business of saving lives.
So what are the lessons that we as therapists can learn from Mr. Farley? 1. Anyone can make a difference in someone’s life. In a therapeutic relationship that might be you, but it also might not be you and that is ok too. What is important is that you help your client’s figure out who that person is and how they can be helpful to them. If it is you, realize how important you are to them. Remember that your act of caring, being sensitive, open and real with them might be what they need to get by and get better in a difficult time in their life. Maybe it is more than one person, and I would suggest that it should be. Help them build a support network of people who can be there for them for all kinds of things that happen in their life. It is also important to help them understand that X or Y person can in fact make a difference for them. Some clients discount certain people in their lives (parents, siblings, neighbors, etc.) and we can help them see the benefits that anyone can bring to their lives. (Of course we want to be mindful that in most cases we don’t know these other people and we are relying on their report(s) of them to help us determine the good/bad they might bring to our client’s life.) The most important thing is that they learn to be open to anyone being someone who can make a difference. In Mr. Farley’s case, the students never thought the principal would care or spend the time with them. They thought that would be saved for their counselor. Mr. Farley showed them that anyone can and will be there for you if they commit to doing so.
2. Sometimes it’s the simple things that make a big difference. Often I hear therapists analyzing and over-analyzing a session or statement a client made. Sometimes therapists look deeper into things that happen in their clients’ lives and while at times that might be important, other times we just need to see and hear things for what they are. At those times we can be very helpful to our clients by letting them know that ‘it is what it is’ and it might just not be any more than that. This is a double-bind therapists get into when they look too deep and/or the clients do. So be ok seeing that the problem or the solution might be much simpler, and help your clients see this as well.
that day and for whatever reason(s), cancel and reschedule. Again, this will be better for your client in the long run than trying to fake being attentive or being caught by your client in your distraction. Therefore, just as Mr. Farley put everything aside when he came across a student who wasn’t able to give him a thumbs-up, recognize that you must give your clients everything that you have focused on them when they are in your office.
4. Develop a way to monitor your clients on how they are doing. From the beginning of your work with them, talk with them about what their baseline is and how they can share where they are at relative to that baseline so you have a sense of this easily and over time. You don’t need to use a thumbs-up or down approach, but you can, especially with children. Another simple way to do this are the old fashioned “where are you today on a 1-10 scale” approach. There is nothing wrong with this and there are many new technological approaches to getting clients to assess themselves just like this on a daily basis through text messages so they can chart their progress on a daily/weekly/monthly basis. I recommend you have a similar way of communicating this between you and your clients to chart their progress in therapy. For some it offers a non-threatening way of sharing where they are at any one particular time.
5. Remember that progress in therapy can be redirected at any moment in the process, and this too can be ok. Mr. Farley’s day never started thinking he would come across a student who needed him. Rather, he thought each day would be something different and he was prepared for that. I have talked with a number of therapists that seem to think/want their clients to come in and keep moving forward with their treatment plan and that is good, as we would like it to be. However, when something in their client’s life has derailed that progress they try and keep bringing them back “on track.” Therapists have a funny way of seeing distractions in client’s lives as a defense mechanism. Sometimes that is true, other times it is not and we must be ready every day for the reality of what is happening in our client’s lives outside of their treatment plan. Finally, always be conscious of the fact that what your client sees as being significant, regardless of what it is, is incredibly important to them. We should be aware that if a client is struggling with someone, something or anything and it is a “10” for them, our job is to help them get it to be more manageable whether that is a relationship, an insecurity or any one of hundred problems clients bring to us. Regardless of what it is, remember that you too are (always) “walkin’ and talkin” with your patients helping them to better navigate their life.
About the Author
3. Give every client your full attention. I’ve written about this before and will say it again…if you can’t fully attend to your client, you should not see them. You will do them the responsible and ethical thing by referring them to someone who can. If it is just 14
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Annals of Psychotherapy & Integrative Health
Daniel J. Reidenberg, PsyD, FAPA, DAPA, MTAPA, is the chair of the American Psychotherapy Association’s Executive Advisory Board and has been a member since 1997. He is a Fellow and Master Therapist of the American Psychotherapy Association and executive director of Suicide Awareness Voices of Education (SAVE) in Minneapolis, Minnesota. Contact him with your thoughts at dreidenberg@save.org. www.americanpsychotherapy.com
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Have we all lost our minds? It’s a question we have all asked ourselves as we ponder such modern occurrences as “reality” TV, road rage, and terrorism. Javors’ collection of her columns from the Annals of the American Psychotherapy Association offers prescriptions for “sane living” in the face of life’s challenges. Paperback. 978098221141 | 144 pages | $14.95
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culture notes too much weight gain and obesity,” and that this “also fuels the use of some treatments, such as those for hypertension.” For the most part, children are given medications that have been tested in adults and not young people. We have no idea what these drugs are doing to children. Mathews quotes Dr. Danny Benjamin, who is “leading a new National Institutes of Health initiative to study drugs in children,” as saying, “we know we’re making errors in dosing and safety.” He suggests that “parents do as much research as they can to understand the evidence for the medicine.” As mental health professionals working with children, teens, parents, and other health care providers, we need to become very well-informed about all the medications that are prescribed for our clients. We need to be cautious in making a diagnosis as well as
Pills, Pills, & More Pills
Medicating Children and Adolescents
n the article “So Young and So Many Pills (Wall Street Journal, December 28, 2010, sec.D, p.1), Anna Wilde Mathews reports that “more than 25% of kids and teens in the U.S. take prescriptions on a regular basis.” She goes on to inform us that “children and teens (are taking a wide variety of ) medications once considered only to be for adults, from statins to diabetes pills and sleep drugs.” She also states that “prescriptions for antihypertensives in people aged 19 and younger could hit 5.5 million this year.” Mathews further informs us that anti-psychotic medications have been prescribed to 6,546,000 young people, with the following breakdown: 1,396,000 to children 0–9 years and 5,150,000 to those 10–19 years; antidepressants to 9,614,000: 1,026,000 to children 0-9 years and 8,588,000, 10–19 years; and medications for ADHD (attention deficit hyperactivity disorder) to 24,357,00: 7,018,000 to ages 0–9 years and 17,339,000 to ages 10–19 years. My first response to reading these statistics: “Wow!” My next: What is going on here? And why are so many of our children and teens suffering from such chronic conditions? Mathews suggests that early detection may account for some of these numbers. She also points out that researchers attribute some of what’s going on to “unhealthy diets and lack of exercise among children, which lead to 16
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making sure to watch out for and identify side effects from the prescribed medication(s). We need to support parents’ efforts to find out as much as possible about the medications that are given to their children. Mathews reports that “parents and doctors also say nondrug alternatives should be explored where possible.” She quotes Tom Wells, professor of pediatrics at the University of Arkansas for Medical Sciences, as saying, “obesity is really the biggest cause I see for high blood pressure in adolescents...but only 10% of families adhere to (his) diet and exercise recommendations.” As counselors, we need to re-evaluate our relationship to medication. Do we suggest medication too quickly? Are there other ways of dealing with the problem? Are we still searching for the “magic bullet,” the quick fix to cure what ails us? How do we find a balance between over-reliance on drugs for symptom relief and finding a drug-free path to cope with and/or overcome pain and ill health? Are these chronically sick children who are suffering from asthma, high blood pressure and cholesterol, depression, bipolar disorder, ADHD, insomnia, and diabetes the proverbial “canaries in the mine,” sending us a loud message that the way we live, now, is making us very sick, if not killing us? I hope that we are listening!
About the author
Annals of Psychotherapy & Integrative Health
Irene Rosenberg Javors is a Diplomate of the American PsychotherapyAssociation, a licensed mental health counselor, and a psychotherapist in New York City. She is also an adjunct associate professor of mental health counseling in the Mental Health Counseling Program of the Ferkauf Graduate School of Psychology at Yeshiva University. She is the author of Culture Notes: Essays on Sane Living (ACFEI Media, 2010). www.americanpsychotherapy.com
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How far havein understanding we come obsessive-compulsive disorder in children and adolescents? By Karin Tochkov, Ph.D.
Suf
fering from
feeling like
to
OCD often
means
a prisoner in your own
mind and body, not being able
enjoy
life
to the
full-
est and having to live a life that is all consumedby
anxiety &
(800) 592-1125
fear
.
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CE article: 1 CE Credit
This article is approved by the following for 1 continuing education credit: The American College of Forensic Examiners International is approved by the American Psychological Association to sponsor continuing education for psychologists. The American College of Forensic Examiners International maintains responsibility for this program and its content. The American Psychotherapy Association速 provides this continuing education credit(s) for Diplomates and certified members, who we recommend obtain 15 credits per year to maintain their status. Measurable and observable learning objectives: Explain the main differences of OCD in children and adolescents versus adults. Discuss epidemiology and clinical features of OCD in children and adolescents. Identify causes and contributing factors of OCD in children and adolescents. Keywords: obsessive-compulsive disorder; childhood psychopathology; epidemiology Target Audience: Psychotherapy researchers, psychologists, psychotherapists Program LEvel: Intermediate Disclosures: The author has nothing to disclose. prerequisites: none
Abstract The purpose of this paper is to review the current empirical literature on obsessive-compulsive disorder in children and adolescents. The results are discussed from a developmental perspective, thus emphasizing different factors responsible for the development and maintenance of OCD in children and adolescents. The main contributing factors include genetic transmission in families as well as the effect of the environment (family, society, culture). The study concludes that a comprehensive theoretical model is needed to take all empirical results into consideration in order to present a developmental explanation of the predisposition, onset, development, and maintenance of OCD in children and adolescents.
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U N D E R S TA N D I N G O C D I N C H I L D R E N A N D A D O L E S C E N T S
Introduction Obsessive-compulsive disorder (OCD) is an anxiety disorder, characterized by obsessive thoughts which cause anxiety and distress and compulsions which aim at neutralizing this anxiety. OCD can take different forms and can cause a high degree of impairment in everyday life. In particular, rituals and other compulsive behavior can be extremely time-consuming. Suffering from OCD often means feeling like a prisoner in your own mind and body, not being able to enjoy life to the fullest and having to live a life that is all consumed be anxiety and fear. Every day life can become unbearable, and even minor tasks might take an eternity to be completed until the never-ending compulsions and rituals are obediently carried out. The more habits to avoid the anxieties that are developed, the harder it will become to face the fear. In the following section, different clinical aspects of OCD in children and adolescents are presented and contrasted with OCD in adults. The different causes of OCD are then briefly summarized. The main body of the paper reviews empirical results of genetic influences and environmental effects on OCD in children and adolescents.
OCD in children and adolescents: Epidemiology and clinical features The essential features of OCD are recurrent obsessions and compulsions that are extremely time-consuming and cause a severe distress and impairment. Obsessions are defined as recurrent thoughts and images, compulsions are defined as recurrent behaviors (American Psychiatric Association, 2000). Obsessions can be about contamination, religion, superstitions and perfectionism. Compulsions can take many different forms, such as decontamination, hoarding, checking, counting, touching, etc. The most important aspect from the developmental perspective is whether OCD in children and adolescents is different from OCD in adults. The classification of OCD in children and adolescents according to the latest edition of DSMIV-TR is similar to that in adults. The exception is that children are not expected to recognize that their obsessions or compulsions are excessive or unreasonable (American Psychiatric Association, 2000). Although the symptoms are distressing somehow to these children, they cannot recognize or express a direct relation between their obsessive symptoms and compromised daily life activities. Moreover, the cognitive development of children may not facilitate the observation and description of his/her own thoughts. Often children may be frightened or confused by their thoughts, making them more likely to hide their symptoms from parents and clinicians. Consequently, children are less likely to report their obsessions and can be underdiagnosed and undertreated. OCD usually emerges during childhood or adolescence. It has been estimated that around 80% of adults with OCD identify their onset of symptoms before age 18 (Pauls et al., 1995). Lifetime prevalence of OCD in adults and adolescents is between (800) 592-1125
1-3%; however, there are no estimates of prevalence of OCD in children (Riddle, 1998). Estimates of the mean age at onset for children and adolescents range between 10 and 11.44 for boys and between 10.2 and 13.5 for girls (Hanna, 1995; Toro et al., 1992). Geller et al. (2001) find in their sample of 101 subjects that mean age of onset is 6 in children, 10 in adolescents and 21 in adults, where all these numbers refer to males. In adults, OCD is equally common in males and females. In contrast, it has been observed that boys have a higher rate of OCD than girls during childhood and adolescence. Hanna (1995) estimates the male-female ratio to be 3:2, Geller et al. (2001) estimates it at 2:1 and observe that boys have both an earlier age of onset and more severe symptoms than girls. A legitimate question stemming from all these differences between children and adults regarding the epidemiology of OCD is how similar juvenile and adult forms of OCD are. Geller et al. (2001) demonstrates that there is a clear discontinuity between the OCD in adults and the OCD in children and adolescents. This result suggests that juvenile OCD is a unique developmental subtype of adult OCD. The preceding discussion of clinical features makes clear that OCD in children and adolescents has many different aspects which demonstrate the importance of a developmental perspective on OCD.
Causes and contributing factors for OCD in childhood and adolescence Several theories have been proposed to explain the development and maintenance of OCD, and the fact that the overwhelming majority of OCD patients have an onset of the disorder in childhood
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or adolescence. Generally, these theories can be divided into biological and genetic models emphasizing the role of genetic factors, neurological processes and brain malfunctions, and psychological models focusing on the influences of cognitive processes, learning of behavior, and environmental factors (family, culture, and religion). The review of the literature in the following sections will focus exclusively on the genetic and the environmental factors which contribute to the pathogenesis of OCD in children and adolescents.
Genetic factors Over the years, many studies have indicated that OCD is likely to have genetic origins. Therefore, there may be an underlying predisposition for OCD to occur in certain children and adolescents stemming from heritable factors. Evidence for genetic influences in the onset of OCD during childhood has come primarily from family and twin studies. Family studies provide one of the common means of analysis of genetic factors since all family members share common genes. There are two techniques used to determine prevalence of OCD in relatives: the family-history method and the family-study method. Early studies applying the family-history method assessed relatives and determined diagnoses based solely on the information provided by the proband. In contrast, more recent studies have used the family-study method, in which all available first-degree relatives are interviewed directly (Billett et al., 1998; Alsobrook et al., 1998). Especially in the case of children and adolescents, the familystudy method appears to be the more suitable alternative since children have more difficulties explaining in detail the obsessivecompulsive behavior of their relatives than adults. Although not as many family studies with children were conducted as with adults, there is nevertheless enough evidence that early onset of OCD in childhood is affected by heritable factors. Riddle et al. (1990) interviewed the parents of 21 children and adolescents between the ages of 7-17 with OCD. Fifteen of them (71%) had a parent with either OCD or obsessive-compulsive symptoms. In other words, 15 of the 42 parents (35.7%) were diagnosed with clinical or subclinical OCD. Unfortunately, this study gives no information concerning siblings or rates of diagnosis in siblings. Moreover, no control group was included which makes conclusions more difficult to make. Lenane et al. (1990) interviewed not only parents but also siblings of 45 children and adolescents with severe OCD. A total of 145 firstdegree relatives were interviewed. Twenty-five percent of fathers and 9% of mothers had OCD. When obsessive-compulsive behavior is included, the risk for all first-degree relatives was 35%. As in the previous study, there was again no control group. Lenane et al. (1990) also looked for any relationship between the children’s primary OCD symptoms and those of their respective relatives. They found no consistent pattern between parents and children, or between older and younger siblings. Hence, it cannot be simply stated that obsessivecompulsive symptoms are observed and learned by younger relatives. Furthermore, in another family study Last et al. (1991) interviewed first and second-degree relatives of 152 children with different anxiety disorders. In contrast to previous studies, a control group of 87 children was also included. The results indicate that a trend for OCD is more prevalent among relatives of children with OCD than among 22
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relatives of children with other anxiety disorders. This in turn suggests that the risk was specific for OCD, and further supports the genetic model of early onset of OCD. Toro et al. (1992) explored parents and siblings of 72 children and adolescents aged 5-18 with a diagnosis of OCD. The majority of the probands (57%) had some first-degree relative with a psychiatric diagnosis, however only 11 probands (15.3%) had a first-degree relative diagnosed with OCD. This result is much lower than the previous studies, but it is mainly due to the procedure used for diagnosing the relatives. No interviews were conducted, only the diagnoses stated in the clinical records of the children were used. Not all studies report such high rates of OCD in families. In particular, phenotype definition and age at onset appear to influence the family aggregation of OCD. For instance, Black et al. (1992) interviewed 120 first-degree relatives of 32 probands with OCD and 33 psychiatrically normal controls. The OCD probands had a mean onset age of 11.04 years. The first-degree relatives of probands with OCD were significantly more likely to experience anxiety disorders than were relatives of controls. However, the prevalence of OCD itself was very low among both groups’ relatives. Only 3% of the relatives of OCD patients were diagnosed with OCD. When obsessive-compulsive behavior was included, this number climbed to 21%. These results indicate that an anxiety disorder may be transmitted in families in which a member has OCD, but its expression within these families is variable. Similarly, Pauls et al. (1995) gathered interview data from 466 first-degree relatives of 100 probands with OCD. The mean onset age here was 10.2 years. In addition, 113 first-degree relatives of 33 psychiatrically unaffected probands were studied with the same interviews. The results show that 10.3% of the relatives were diagnosed with OCD as compared to only 1.9% in the control group. Eight percent of relatives were diagnosed with obsessive-compulsive behavior. These results, paired with those from the study by Black et al. (1992) indicate that OCD is a heterogeneous condition. Some cases were familial, but in other cases there appeared to be no family history of OCD. However, there was a two-fold increased risk for OCD and a four-fold increased risfor obsessive-compulsive behavior in relatives of probands with childhood-onset OCD as compared to a later onset (after the age of 18). This is a sign that an early onset of OCD can be interpreted as a more severe form of the disorder with a greater genetic loading. This certainly distinguishes OCD in children and adolescents from OCD in adults. In a more recent family study, similar results were achieved. Nestadt et al. (2000) interviewed 80 probands with OCD and 343
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U N D E R S TA N D I N G O C D I N C H I L D R E N A N D A D O L E S C E N T S in relatives of probands with later onset was 0 (0%) of 49. Thus, no cases of OCD were found in the case of relatives of probands with late onset of OCD. In other words, the younger the age at onset, the higher the familiality of OCD. This suggests that cases of OCD with early age at onset are more likely to yield information about the genetic origins of this disorder – a further sign that developmental aspects and genetics are intertwined in the case of OCD. Black et al. (1992) and Pauls et al. (1995) have observed that OCD in children and adolescents can be a heterogeneous condition, with some cases being familial and others not. Albert et al. (2002) conducts the most recent family study with 74 probands with OCD onset in childhood and adolescence (mean onset age is 12.1 years). First-degree relatives were diagnosed either using the family-history or the family-study method. Eleven percent of the probands had at least one family member with OCD, which is again in the range of previous estimates. The interesting result of this study however is the finding that there is no significant difference between the phenomenological characteristics of OCD probands with OCD family members and OCD probands with normal family members. In summary, family studies suggest that genetic factors lead to a certain vulnerability of children and adolescents to develop OCD. The estimates of the rate of OCD in first-degree relatives from the studies discussed above range from 3% to 15%. However, if the obsessive-compulsive behavior of first-degree relatives is included, then the range increases to 17-35%, which is overwhelmingly higher than the normal prevalence rate of 1-2%. The big differences in the estimates appear to be mainly due to different methodologies used. As already mentioned, some include control groups, other did not. Some base their diagnoses of the The relatives from direct structured interviews, other used data from existing data on relatives in the folders of result of this study child probands. Despite all those differences, the rehowever is the finding that sults of the family studies are in favor of a heritable factor in OCD. Moreover, symptom patterns have significant difference between generally been observed to differ between probands and relatives, making an environmental explanation the characteristics less likely. of OCD probands with OCD Besides the traditional family studies on OCD, more recent studies on family transmission have focused on members and probands with comorbidity between OCD and other disorders. Bellodi family et al. (2001) proposed for instance that eating disorders should be considered a specific type of OCD. They found that the morbidity risk for obsessive-compulsive spectrum disorders was significantly higher among the first-degree relatives of the eating disorder probands (adolescent females) than among the of their first-grade relatives of the controls. Grados (2001) examined whether tic disorders relatives. A control are part of the familial phenotype of OCD. Their results show that OCD group of similar dimensions probands and their first-degree relatives had a greater lifetime prevalence of tic was included. The first-degree relatives disorders compared to controls. Younger age-at-onset of OCD symptoms and of probands diagnosed with OCD had a nearly male gender in the OCD probands were associated with increased tic disorders 5-fold higher lifetime prevalence of OCD when in relatives. Such studies are limited by being unable to neutralize the environcompared to the controls. The median age at onset mental effect contrary to adoption studies and particularly the subtype of cross of symptoms was about 11 years; more than 75% fostering design to exclude environmental effects, although no research articles of the probands had onset by age 14 years, and are available with this methodology as the case for adults. 90% by age 17 years. The prevalence of OCD in Twin studies have provided some additional evidence for the heritability of the relatives of probands with an onset age below OCD. These studies provide some indication of the relative rates for concordant 17 was 38 (13.8%) of 276, whereas the prevalence and discordant Monozygotic and Dizygotic twin pairs. The method used consists
interesting
no
there is
phenomenological
OCD
family
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members.
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Authors
Bellodi et al. (2001)
Black et al. (1992)
Nestadt et al (2000)
Grados et al. (2001)
Sample size / Mean Age
Methodology
Probands n = 136 (M = 22.12; SD = 4.93) Controls n = 72 (M = 39; SD = 12.84) Case Relatives n = 436 Father: M = 53.54; SD = 7.60 Mother: M = 49.80; SD = 8.90 Brothers: M = 23.30; SD = 9.21 Sisters: M = 22.97; SD = 8.71 Control Relatives n = 358 Father: M = 64.63; SD = 12.22 Mother: M = 61.87; SD = 11.73 Brothers: M = 36.97; SD = 14.97 Sisters: M = 43.20; SD = 14.57
Utilized family study and family history methods.
Probands n = 32 (M = 38.3; SD = 10.9) Controls n = 33 (M = 38.1; SD = 10.0) Case Relatives n = 120 (Interviewed) M = 41.8; SD = 15.7 Control Relatives n = 129 (Interviewed) M = 41.1; SD = 15.7
Utilized family study and family history methods.
Probands n = 80 (M = 36.6; SD = 11.6) Controls n = 73 (M = 38.5; SD = 11.8) Case Relatives n = 343 (M = 48.1; SD = 18.9) Control Relatives n = 300 (M = 44.5; SD = 18.8)
Utilized family study and family history methods.
Probands n = 77 Controls n = 66 Case Relatives n = 323 Control Relatives n = 289
Studied the prevalence of obsessive-compulsive spectrum disorders in first-degree relatives of probands with eating disorders.
Results The morbidity risk for obsessive compulsive spectrum disorders was found to be higher among relatives of eating disorder probands in comparison to the control group. These findings were independent of a comorbid obsessive compulsive spectrum disorders in the eating disorder probands.
Proband inclusion was determined by clinical diagnosis First-degree relatives of probands were interviewed directly or were evaluated by family history methods to determine symptoms.
Included OCD and subsyndromal OCD symptoms Probands met DSM-III criteria for OCD. Relatives were evaluated with structured and unstructured interview methods as well as several scales and inventories
Probands met DSM-IV criteria for OCD.
The morbidity risk for anxiety disorders was increased among the relatives of OCD participants, but the risk of OCD was not. First-degree relatives of probands with OCD are significantly more likely to experience anxiety disorders than relatives of psychiatrically normal controls. Risk for obsessive compulsive symptoms (not meeting the full criteria for OCD) was increased among parents of OCD participants but not among the parents of controls
The lifetime prevalence of OCD was significantly higher in case relatives when compared with control relatives
Collected data on OCD as well as obsessions and compulsions
The prevalence of definite and probable OCD was higher in case relatives
Relatives were evaluated with direct interviews using structured and semi-structured instruments; family history information was collected through informant; various inventories were used
Case relatives had higher rates of both obsessions and compulsions – obsessions are more specific to familial aspect of OCD
Utilized family study and family history methods.
Case probands and case relatives had a greater lifetime prevalence of tic disorders compared to control subjects.
Probands met DSM-IV criteria for OCD. Probable and definite diagnoses of tic disorders and OCD were considered in the analysis.
First-degree relatives with OCD with tic disorders have an earlier age-at-onset of OCD symptoms compared to those that have OCD without tic disorder
The prevalence and severity of tic disorders and age-at-onset of OCD symptoms and were analyzed in relatives
Younger age-at-onset of OCD symptoms were associated with increased tic disorders in relatives.
Symptoms and severity were assessed by direct interviews, collateral informants, as well as several scales
24
Fall / Winter 2011
Annals of Psychotherapy & Integrative Health
www.americanpsychotherapy.com
Last et al. (1991)
Lenane et al. (1990)
Methodology
Anxiety Probands n = 94 ADHD Probands n = 58 NPI Probands n = 87 Anxiety Case Relatives First Degree – n = 274 Second Degree - n = 812 ADHD Case Relatives First Degree – n = 152 Second Degree – n = 484 NPI Case Relatives First Degree – n = 240 Second Degree – n = 718
Utilized family study and family history methods.
Probands n = 46 Case relatives n = 145
Utilized family study and family history methods.
First and second-degree relatives of children with anxiety disorders were compared with relatives of children with ADHD and children who have never had a psychiatric condition.
Results Increased prevalence of anxiety disorders in the first-degree relatives of children with anxiety disorders compared with relatives of children with ADHD and normal controls
Probands met DSM-III-R criteria for their OCD or ADHD
OCD and panic disorder were the only two anxiety disorders that showed a suggestion of a specific relationship in children and their relatives.
Utilized direct structured interviews and diagnostic scales, as well as the family history method with first-degree relatives.
The specificity of the familial component involved in childhood anxiety disorders varies between disorders.
Second-degree relatives were assessed using the family history method.
Structured interviews, family histories and several inventories were used to assess DSM-III OCD criteria, subclinical OCD and related symptoms, and other psychiatric disorders
30% of case probands had at least one first-degree relative with OCD - 45% of fathers and 65% of mothers received one or more other psychiatric diagnosis. Results showed a larger familial rate of OCD over what is expected in the general population The presenting obsessive-compulsive symptoms of case probands and their parents were usually dissimilar, which argues against simple social or cultural transmission.
Pauls et al. (1995)
Albert et al. (2002)
Probands with OCD n = 100 Probands without OCD n = 33 OCD Case Relatives n = 466 Non-OCD Case Relatives n = 113
Utilized family study and family history methods.
Probands n = 74 (M = 34.3; SD = 11.8) Case Relatives n = 251 (Total) n = 231 (Directly interviewed; M = 42.5; SD = 21.3)
Utilized family study and family history methods.
N/A
Riddle (1998)
Probands met criteria for DSM-III-R OCD. Definite and probable (sub-threshold) diagnoses were used in analysis Available first-degree relatives were interviewed directly with structured interviews, and family histories were taken from each informant using a semi-structured interview. Several scales were also used to assess symptoms.
Probands met DSM-IV criteria for OCD
The rates of OCD and sub-threshold OCD were significantly greater among the relatives of the case probands with OCD than among the comparison subjects. The rates of tics were also significantly greater among the relatives of the case probands than among the comparison subjects. The relatives of case probands with early onset were at a higher risk for both OCD and tics
11% of the case probands had at least one family member with OCD.
Utilized structured and semi-structured clinical interviews as well as rating scales with available relatives.
There were no differences between the two types of OCD (familial versus non-familial) except for life events prior to the onset of OCD, which were more common and more severe.
Information about unavailable relatives was collected through structured family history interviews with the proband and other family members as informants.
There is a familial component in the expression of some forms of OCD.
Data was collected on specific OCD symptoms and phenomenology
Familial OCD patients are not characterized by peculiar clinical features, but appear to have a lower threshold for precipitating events. in non-familial OCD subtypes.
Provides and overview of pediatric OCD in terms of age of onset, classification, subtypes, prevalence, assessment, prognosis, and treatment.
Treatment components include long-term commitment, care management, and illness education—including CBT, behavior management, and medication. The most effective treatments are SSRIs and exposure/response prevention.
Toro (1992)
Probands n = 72 (M = 12.0; SD = 3.29) Control n = 72 (Matched for age, sex, and date of consultation)
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Clinical records of children with a DSM-III-R diagnosis of OCD were examined.
57% of case probands had some first degree relative with a psychiatric diagnosis
The presence of psychiatric history in first-degree relatives was examined. Only diagnoses formulated by specialists and stated in clinical records of obsessive children were considered.
15.3% of first-degree relatives were diagnosed with OCD.
Annals of Psychotherapy & Integrative Health
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25
U N D E R S TA N D I N G O C D I N C H I L D R E N A N D A D O L E S C E N T S
Sample size / Mean Age
Authors
CE article: 1 CE Credit of comparing the number of MZ twins in which both members have OCD with the number of corresponding DZ twin pairs. If the concordance of MZ twins is higher than in DZ twins, genetic factors are certainly contributing to the development of OCD. Unfortunately, no recent twin studies exist. But in general studies from 1980s and early 1990s find a concordant MZ:DZ ratio of 2:1 for OCD, which further supports the effect of genes on the onset of OCD in children and adolescents (Billett et al., 1998). Family aggregation of OCD is necessary, but not sufficient, for the interference of genetic transmission, because parents and relatives transmit not only genes to their children, but also sociocultural factors that can lead to different phenotypes. In other words, common environmental factors can also contribute to the development of OCD in children with different genes. The best way to analyze environmental factors is to conduct adoption and separation studies. Unfortunately, such studies are nonexistent in the context of OCD due to the fact that extremely few children or twins with OCD are taken apart and adopted by different families. Studies on twins (concordance rate among monozygotic twins sharing 100% of the nuclear DNA versus dizygotic twins sharing only 50% of nuclear DNA) and adoption studies are lacking in the literature for this specific age group. Once genetic factors were found to play a role in the early onset of OCD during childhood and adolescence, the main focus of research shifted away from family and twin studies, and concentrated on the application of DNA technology to the study of OCD. Therefore, most recent literature on the genetics of OCD is found in the area of molecular genetics where researchers try to isolate the specific genes (the common genes implicated in the etiology of OCD like those of MAO-B enzyme on the X chromosome, 5-HT reuptake proteins, 5-HT 2a and 2c receptors) which seem to be responsible for the early onset and development of OCD (Pato et al, 2002).
Psychological factors While OCD is widely recognized to have a strong genetic component, psychosocial factors are also acknowledged to be important. The primary focus of this section is on familial and cultural/religious context as possible risk factors in the development and maintenance of the disorder in children and adolescents. Freeman et al. (2000) presents the case of 10-year old boy and a 7-year-old girl diagnosed with OCD. The boy had been repeatedly sexually abused by an older peer, and the obsession concerning contamination by germs and sexual images started immediately after the abuse stopped. No family history of OCD was found in the family, thus environmental factors (abuse by peers) seem to be the trigger of OCD. The case of the girl involves an incident of unwanted “sex play” with a peer. After this incident compulsive hand washing rituals developed. This shows the important role of guilt feelings of being the victim to sexual abuse provoked by the conscience in OCD psychopathology. When subjected to traumatic events children and adolescents often blame themselves. A common example of that is that many children see themselves as the reason their parents marriage ended in divorce and moreover interpret the events leading up to it as if they were among causes of such divorce. Children with their immature cognitive structures may have their own way of attributing cause-event relation, and are more liable for 26
Fall / Winter 2011
self-blaming. The mother of the girl had OCD, which is a possible factor for the predisposition of her daughter, but the trigger was clearly an environmental factor (the “sex play”). These two cases suggest that OCD is a heterogeneous condition. Genetics can play a role, but environmental factors can be not only a trigger but the main reason for developing OCD in children. A more recent study by Lochner et al. (2002) explores the link between a traumatic event in childhood and the development of OCD in children and adolescents. 74 female probands and 31 controls were included in the study. The age of the probands was as low as 12, but there were no exact numbers on the percentage of children or adolescents. The OCD probands exhibit much higher rates of severe childhood trauma (sexual and physical abuse as well as emotional neglect) than the controls, thus indicating that traumatic events in the childhood may be the reason for the early onset of OCD. This finding is further supported by Mangold et al. (2000) who found that boys with a family history of alcoholism reported more obsessive-compulsive behavior than females and controls. Religion as a part of the cultural and familial environment can also play a key role in the genesis of OCD in children and adolescents. Although the epidemiology of OCD appears to be stable across cultures (Weissman et al., 1994), patients with religious obsessions may be over-represented in clinical populations of Muslim and Jewish cultures, as compared with clinical populations from the West and the Far East. The frequency of religious obsessions in clinical populations diagnosed with OCD is reported to be between 5-10% in USA and Western Europe, as compared to 4060% in Saudi Arabia, Israel and Egypt (Tek et al., 2001). Tek et al. (2001) conducted a study with 45 patients diagnosed with OCD in Turkey. Religious obsessions were the main symptom of OCD in nineteen of the patients. Patients with religious obsessions, many of them adolescents, were significantly younger than patients without them. A family history of OCD characterized 40% of the patients without religious obsessions and 45% of those with religious obsessions. Although the study does not mentioned whether the OCD of the relatives was religious in nature, it can be concluded that such a high percentage of genetic loading is improbable when compared with the results of the family studies in the section on genetic factors above. It is more likely that religious obsessions and rituals performed by parents were observed by children and adolescents and contributed strongly to the development of OCD, without neglecting the fact that genetics play a role in the vulnerability and predisposition of such children. Moreover, religious rituals often involve decontamination and purification practices. In many religions the blasphemous thoughts are brushed off through repeated prayers or alleviating the guilt about committing a sin through confession in certain cultures. All these factors certainly increase the development of obsessive thoughts and compulsive behaviors based on religious teachings and practices. In some societies, religion plays a more dominant role than in others. Under pressure by society, family, and peers, or through education in religious schools, children and adolescents are more likely to develop OCD with religious obsessions. Rituals are more common in Muslim and Jewish cultures, as both have many rituals as part of their religious practice representing a medium to carry those obsessive symptoms. For example it is common in religions like Islam to pray several times a day at
Annals of Psychotherapy & Integrative Health
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U N D E R S TA N D I N G O C D I N C H I L D R E N A N D A D O L E S C E N T S specific scheduled times during the day and night. Washing rituals and other practices may be included in the daily activities of a person’s life. Blasphemous thoughts as a medium for obsessive thoughts are quite common in communities where religious practices are widely present. The most recent study in the area takes religious education into account. Sica et al. (2002) After this incident examined 165 probands which were classified in three groups according to the degree of their religiosity. All probands were from Italy, a country where the Catholic religion plays a central rituals role in the society. One central question in determining the religiosity was regarding attending a religious (Catholic) developed. This shows school. Individuals with a high or medium degree of religiosity showed higher levels of OCD than individuals the important role of with a low degree of religiosity of the same age, educafeelings of tion and gender. Furthermore, perfectionism was one of the dominant symptoms, which the authors link to being the to the teaching of the Catholic religious thought at relisexual abuse provoked gious schools. Okasha et al. (2001) studied the prevalence of obby the sessive-compulsive symptoms (OCS) in a large sample in of Egyptian adolescents. The risk and cultural factors associated with obsessive compulsive behavior include psychopathology. female gender, and first born, with aggressive, contamination, religious obsessions, and cleaning compulsions being most common. In summary, recent evidence indicates that besides genetic factors, environmental factors can play an important role in explaining the early onset of OCD in children and adolescents. Traumatic events or familial relations can be the main trigger for OCD in children without any family history of OCD. At the same time, environmental factors can be the decisive event that unleashes an underlying genetic vulnerability to OCD in children with family history of OCD.
pulsive hand washing
com-
guilt
victim
conscience
OCD
Conclusions One of the main features of OCD is its onset which begins for the overwhelming majority of patients in childhood or adolescence. Many different developmental theories have been suggested in order to explain the early onset of OCD and its contributing factors. Genetic models emphasize the genetic transmission of OCD from one generation to the next, neurological models suggest different malfunctions in the brain which in turn influence behavior, psychological studies have focused on cognitive distortions and psychosocial factors as the main contributors to the pathogenesis of OCD, and learning theories use conditioning to explain the onset of obsessions and compulsions. Although each of these theories has a certain degree of empirical support, there is no comprehensive model that can evaluate and order the different developmental pathways involved in the pathogenesis of OCD. Bolton (1996) proposes a neurodevelopmental pathway and a cognitive developmental pathway, but disregards genetics and environmental factors such as cultural and familial aspects. Epidemiological and clinical data from a variety of cultural and geographic settings on obsessive-compulsive disorder, and many of the obsessive-compulsive spectrum disorders, suggest that this is a group of disorders with a good degree of transcultural homogeneity (Matsunaga & Seedat, 2007). However, the content and themes that predominate in patients with these disorders and the course of the illness can be shaped by cultural, ethnic, and religious experiences. Across cultures, OCD is commonly comorbid with mood, anxiety and impulse-control disorders. (800) 592-1125
Annals of Psychotherapy & Integrative Health
Fall / Winter 2011
27
CE article: 1 CE Credit Future research in different areas such as molecular genetics, neurobiology, cognitive psychology, etc. should not emphasize so much the specific perspective, but should try to integrate different approaches and empirical finding in order to better explain the development and maintenance of OCD in children and adolescents.
Okasha, A., Ragheb, K., Attia, A. H., Seif El Dawla, A., Okasha, T. & Ismail, R. (2001). L’Encephale, 27(1), 8-14)
References
Riddle, M., Scahill, L., King, R., Hardin, M., Towbin, K. (1990). Obsessivecompulsive disorder in children and adolescents: Phenomenology and family history. Journal of the American Academy of Child and Adolescent Psychiatry, 19, 766-772.
Albert, U., Maina, G., Ravizza, L., Bogetto, F. (2002). An exploratory study on obsessive-compulsive disorder with and without a familial component: Are there any phenomenological differences? Psychopathology, 35(1), 8-16. Alsobrook, J., & Pauls, D. (1998). The genetics of obsessive-compulsive disorder. In: Jenike, M., Baer, L. (eds.): Obsessive-compulsive disorders: Practical Management, Toronto: Mosby. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed., Text revision). Washington, DC. Bellodi, L., Cavallini, M., Bertelli, S., Chiapparino, D., Riboldi,, C., Smeraldi, E. (2001). Morbidity risk for obsessive-compulsive spectrum disorders in firstdegree relatives of patients with eating disorders. American Journal of Psychiatry, 158(4), 563-569. Billett, E., Richter, M., Kennedy, J. (1998). Genetics of obsessive-compulsive disorder. In: Swinson, R., Antony, M., Rachman, S., Richter, M. (eds.): Obsessive-compulsive disorders: Theory, research, and treatment. New York: Guilford. Black, D., Noyes, R., Rise, B., Goldstein, R., & Blum, N. (1992). A family study of obsessive-compulsive disorder. Archives of General Psychiatry, 49, 362-368 Bolton, D. (1996). Annotation: Developmental issues in obsessive compulsive disorder. Journal of Child Psychology and Psychiatry, 37, 131-137. Evans, D., Leckman, J., Carter, A., Reznick, J., Henshaw, D., & Pauls, D. (1997). Ritual, habit and perfectionism: The prevalence and development of compulsive-like behavior in normal young children. Child Development, 68, 58-68. Freeman, J., Leonard, H. (2000). Sexual obsessions in obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 39(2), 141-142. Geller, D., Biederman, J., Faraone, S., Agranat, A. (2001). Developmental aspects of obsessive-compulsive disorder: Findings in children, adolescents, and adults. The Journal of Nervous and Mental Disease, 189 (7), 471-477. Grados, M. (2001). The familial phenotype of obsessive-compulsive disorder in relation to tic disorders: The Hopkins OCD Family Study. Biological Psychiatry, 50 (8), 559-565. Hanna, G. (1995). Demographic and clinical features of obsessive-compulsive disorder in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (1), 19-27. Last, C., Hersen, M., Kazdin, A., Orvaschel, H. (1991). Anxiety disorders in children and their families. Archives of General Psychiatry, 48(10), 928-934. Lenane, M., Swedo, S., Leonard, H. (1990). Psychiatric disorders in first-degree relatives of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 407-412. Leonard, H., Goldberger, E., Rapoport, J., Cheslow, D., & Swedo, S. (1990). Childhood rituals: Normal development or obsessive-compulsive symptoms? Journal of the American Academy of Child and Adolescent Psychiatry, 29, 17-23. Lochner, C., du Toit, P., Seedat, S., Niehaus, D., Stein, D. (2002). Childhood trauma in obsessive-compulsive disorder, trichotillomania, and controls. Depression and Anxiety, 15(2), 66-68. Mangold, D., Peyrot, M., Giggey, P., Wand, G. (2000). Endogenous opioid activity is associated with obsessive-compulsive symptomology in individuals with a family history of alcoholism. Neuropsychopharmacology, 22(6), 595-607. March, J., & Leonard, H. (1996). Obsessive-compulsive disorder in children and adolescents: A review of past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 35(10), 1265-1273. Matsunaga, H. & Seedat, S. (2007). Obsessive-compulsive spectrum disorders: Cross-national and ethnic issues. CNS Spectrums, 12(5), 392-400 Nestadt, G., Samuels, J., Riddle, M., Bienvenu, J. & Liang, K. (2000). A family study of obsessive-compulsive disorder. Archives of General Psychiatry, 57, 358-363.
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Pato, M., Pato, C., Pauls, D. (2002). Recent findings in the genetics of OCD. Journal of Clinical Psychiatry, 63 (Supp. 6), 30-33. Pauls, D., Alsobrook, J. I., Goodman, W., Rasmussen, S., & Leckman, J. (1995). A family study of obsessive-compulsive disorder. American Journal of Psychiatry, 143, 76-84.
Riddle, M. (1998). Obsessive-compulsive disorder in children and adolescents. British Journal of Psychiatry, 173 (Supp. 35), 91-96. Sica, C., Novara, C., Sanavio, E. (2002). Religiousness and obsessive-compulsive cognitions and symptoms in an Italian population. Behaviour Research and Therapy, 40(7), 813-823. Tek, C., Ulug, B. (2001). Religiosity and religious obsessions in obsessive-compulsive disorder. Psychiatry Research, 104(2), 99-108. Toro, J., Cervera, M., Osejo, E, Salamero, M. (1992). Obsessive-compulsive disorder in childhood and adolescence: A clinical study. Journal of Child Psychology and Psychiatry, 33, 1025-1037. Valleni-Basile, L., Garrison, C., Jackson, K., Waller, J., McKewown, R., Addy, C., & Cuffe, S. (1994). Frequency of obsessive-compulsive disorder in a community sample of young adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 782-791. Weissman, M. M., Bland, R. C., Canino, G. J., Greenwald, S., Hwu, H. G., Lee, C. K., Newman, S. C., Oakley-Browne, M. A., Rubio-Stipec, M., & Wickramaratne, P. J. (1994). The cross national epidemiology of obsessive compulsive disorder. Journal of Clinical Psychiatry, 55(Suppl), 5-10.
About the Author
Dr. Karin Tochkov is an Assistant Professor and Director of the Master’s Program in Clinical Psychology at Texas A&M University – Commerce. A native of Germany, she completed her undergraduate work in Psychology at the Ruprecht Karls University in Heidelberg, Germany. She received her Ph.D. in Clinical Psychology from the State University of New York at Albany in 2007. As head of the Addictive Behaviors Research Laboratory, Dr. Tochkov’s research focuses on the role of emotions and cognitive distortions in the development and maintenance of addictive behaviors. The results of her research have been presented at several national and international conferences, including the Annual Convention of the Association for the Advancement of Behavior Therapy, the British Psychological Society Annual Meeting, and the World Congress of Psychology. Her publications have appeared, among others, in Judgment and Decision Making and International Gambling Studies. At Texas A&M University - Commerce, Dr. Tochkov regularly teaches graduate classes in Psychopatholgy, Assessment, and Group Psychotherapy. On the undergraduate level Dr. Tochkov teaches classes in Abnormal Psychology and Theories of Personality. She is also chairing the dissertation and thesis committees of students in the Educational Psychology Ph.D. program and the Master program in Clinical Psychology at Texas A&M University – Commerce. In 2010 Dr. Tochkov received the Provost Award for Research & Creative Activity at Texas A&M University - Commerce and in Spring 2011 the Student Recognition Award for Teaching Excellence from the Texas A&M University System.
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2011
Executive Summit Wrap-up
T
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Highlights of the event included keynote addresses by Branson comedian/positive psychologist Yakov Smirnoff, Lt. Col. Dave Grossman, Dr. Tieraona Low Dog, and Dr. Howard Schubiner.
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Association members attended sessions on a wide variety of topics including optimizing cardiovascular health, coaching, medicalization, grief, and many other unique and interesting topics. In addition to some amazing speakers and presenters, Thursday night included a beautiful annual banquet with a surprise performance of “Thriller” by Dr. O’Block and several association staff, followed by a juggler/comedian. It was an entertaining occasion for everyone who attended. Be sure to mark your calendar for the 2012 Executive Summit to be held at the Rio in Las Vegas, Nevada, October 17-19. Remember to register soon to get the best registration rate. We look forward to seeing you there!
Branson, Missouri October 12 –14
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New Members William P. Andrews Mary Buell Raymond E. Butts Alison D. Chozen Renee’ B. Edwards Holly A. Finlay Jenny Ann Frank Jose A. Gonzalez Anna K. Hultquist Carol D. Hults Kenneth R. Lacerte Erica R. Leahy Donna Mahoney Marilyn M. Meyer Salvador G. Morote-Sanchez Carmen Ochoa Charles H. Paris Antoinette Pasquale Alex Queralt Yakov Smirnoff Jeri Smith Henry Clay Stringer Tabitha S. Taylor Robin D. Van Keuren Robert E. Van Meir Susan L. Wald Lucille Williams Patricia Wissen Ada H. Gonzalez-Delgado Jason Paul Kellogg Mary McNeish Stengel Rhonda L. Thomas Pranav Jagdish Patel Sanjai M. Thankachen Maria Gabriela Lozano-Corona Iran Neal Cohen Alicia Lomba Edward Robinson
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Fall / Winter 2011
Nancy R.F. Miller Michael H. Cox Lynn J. Buchanan Janet R. Busic David J. Williamson Velma Benjamin Hypolite Kevin D. Curry, III Audre B. Taylor Eugenia Steingold Jeri Smith Debra Kay Reed Emerald Veronica Wallace-Banks Alison D. Chozen Tabitha S. Taylor Susan L. Wald Jose A. Gonzalez Renee’ B. Edwards Robin D. Van Keuren Lee Urban Natalie Linn Ivey Dawn E. Horwitz-Person Catherine A. Ensana Charne D. Furcron Regina A. Ajunwa Sonya M. Anderson Trudy A. Roach
New LIfe Members Siavash Tabrizy
NEW DIplomates Ada H. Gonzalez-Delgado Dennis Guttsman Franca M. Mancin Pranav Jagdish Patel Richard A. Pessagno Mary McNeish Stengel Sanjai M. Thankachen Rhonda L. Thomas
NEW fellows Daniel H. Decker Diana Hopkins Stephen J. Johnson Siavash Tabrizy
New Members Nasser A. Al-Fureih George C. Anazia Anthony M. Antonacci Jeffrey T. Beasley William Wing H Chau Joseph Di Turo James A. Eckert Pamela S. Eckmann Penelope Edward Conrad Robert Scott Francis Mitzi Gold Dalibor I. Hradek Sanjay K. Jain Brian P. Jakes Reynold M. John James R. Jonas Robin Saraswati Markus Marlena Deborah McCormick Christopher McKinney Adele McMormick Dennis McSeaton Marcus E. Meekins Zev Mellman Gregory T. Olson Chrysanthe Parker Susan Peach Dean E. Raffelock Tobias R. Reid Charles E. Renner Katerina Rozakis-Trani, Fred James Schultz Anthony Serle Hannibal Silver Mathew Alexander Snider Carolyn Williams-Orlando June Ann Wright Meymand
Annals of Psychotherapy & Integrative Health
Anthony M. Antonacci, NMD, DC Penelope Edward Conrad Mitzi Gold, Ph.D, LCSW, MPH Brian P. Jakes, Jr. Reynold M. John James R. Jonas Khadra A. Kahin Robin Saraswati Markus Christopher McKinney Marcus E. Meekins Judy K. Melius Zev Mellman Mary Helen McFerren Morosko Casseday Katerina Rozakis-Trani Fred James Schultz Mathew Alexander Snider Thomas M. Wnorowski June Ann Wright Meymand
NEW DIplomates William Wing H Chau Reynold M. John Thomas K. Lo Marcus E. Meekins Leon Mellman Mary Helen McFerren Morosko Casseday Gregory T. Olson Richard P. Petri, Jr Dean E. Raffelock Fred James Schultz Yakov Zilberman
NEW fellows Tetsuya Hirano Stephen D. Newman Arnold M. Sandlow Nhan Thien Tong
www.americanpsychotherapy.com
Annals of Psychotherapy &
Integrative health Chuck Mercer / Tai Chi instructor at St. Johns Fitness Center, Springfield MO for 20 years.
Tai Chi was brought about for creating a balance between mind, body, and nature, while encouraging a heightened state of health and wellness.
35 the art of tai chi 46 natural remedies: milk thistle 56 guided meditation for waking up and coming home (800) 592-1125
Annals of Psychotherapy & Integrative Health
Fall / Winter 2011
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ndation with u o f the ga n i t for ts, and creatin ea n m r e ga c h w i ,b e l m e h t t e d l r l v u ela uil o ts, a di m en ti ng p m o r , vita in (Qi) ve l i g en h th C e ; r s o p eJ , i r r e n it, g e c in h w n S i g t d h i an
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By Trysta Herzog
Tai Chi History By watching the slow, deliberate, and graceful steps of tai chi, the last use you might envision for the beautiful art form would be as a self-defense tool. However, out of the development of martial arts about eight centuries ago, tai chi was brought about for just that purpose: creating a balance between mind, body, and nature, while encouraging a heightened state of health and wellness. Tai chi opponents are not met with the same rigidity of other Chinese martial arts—force meeting with force—but with deflection and using the attacker’s own force against him. The five leading tai chi styles—Chen, Yang, Wu/ Hao, Wu, and Sun, respectively—are connected in their history as well as the energies they attempt to stimulate within their practitioners; they differ, however, in their interpretations of the original 13 movements and form.
Tai Chi Philosophy
Master Yang Jun
For 20 years, Yang Jun said he’s taught many different types of students, but sees a commonality between them. “People come to try to understand life—try to find balance and understanding from tai chi,” he said. “You are following the philosophy of the kite in practice. It is through constant practice, he said, that this inner peace can be reached, especially when you’re practicing with another person. “Movements come from outside of things; it is the balance between you and another. Tai chi is very simple, but two things that keep changing—movements like left hand, right hand, left hand, right hand—it becomes very complicated.” Tai chi is about creating a foundation with the form, building on the method with movements, and creating a relationship between movements, all the while developing the Jing, or essence; Chi (Qi), or vital energy; and Shen, or spirit, within. “If you just know the movements, there’s no meaning behind it. First you have the philosophy to guide you, and then the steps will gradually show you how to do it. Nurture your energy, your skill, and your foundation.”
Master Yang Jun
5
Tai Chi Styles
www.yangfamilytaichi.com
Chen: Fast and slow combined together with some jumping and stomping movements. Old form and cannon fist was created from the 17th generation. yang: Started from the old form/frame from the Chen family. Yang movements are slow, even, gentle, big, and large.
wu/hao: First Wu style came from Yang and Chen styles and is slow, smooth, and small, and the posture is high with a smaller frame.
wu:
Second Wu style comes from Quanyu who learned from Yang Ban Hou. They lean their body to the side, but when they lean they think about being straight.
sun: Movements combine three styles of tai chi together, Wu, Hsing-I, and Bagua. 38
Fall / Winter 2011
Master Yang Jun
Master Yang Jun
Originating in the Hebei province of China during the early 1800s, the Yang style was first developed by Yang Lu Chan, who had been sent at a young age to train with the 14th generation Chen family. He later was hired to train the Chinese Imperial family. Now, six generations later, Master Yang Jun is keeping alive his family’s tradition of teaching others the martial art. “At the beginning it was not my intention to start practicing tai chi,” he said. “I was actually just scared to be by myself.” At five years old, Yang lived in China with his grandfather Master Yang Zhen Duo, who like many other Chinese residents practiced tai chi early each morning. “My grandfather would lock me in the room and leave. I was scared, so the next day I ask, ‘Please take me with you.’ Sometimes after school, I wanted to play with the other kids, but my grandfather made me practice. I didn’t know it then, but he wanted to have someone to continue the family art.” Now proficient in tai chi chuan, sword, saber, push hands, and many other forms of tai chi, 43-year-old Yang Jun has operated a tai chi school in Seattle, Washington, since 1999 with his wife, Fang Hong—also a tai chi instructor—and their two children. The year before that, he began the International Yang Family Tai Chi Chuan Association. He is also the first in the Yang family to live outside of China, taking with him the Yang style to teach across the United States and the world.
Annals of Psychotherapy & Integrative Health
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