Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

The Power of Expectations

A recent study found that parents’ stereotypes about teen rebelliousness fuel’s teens’ misbehavior. In this longitudinal study, researchers interviewed a large sample of 6th and 7th graders and their parents regarding expectations for the child’s behavior as he or she enters adolescence. At the one-year follow-up, teens whose parents had negative expectations about their child falling into stereotypical teenage behavior (e.g., drugs, premature sexual activity, rule-breaking) were more likely to have engaged in these behaviors. This was true even after controlling for many other predictors of such behaviors.

My guess is that several factors may be at play here:

1.) Parents whose sons and daughters had behavior problems during childhood may be more likely to have negative expectations as their child enters adolescence. Indeed, having a history of childhood conduct problems does increase the likelihood of engaging in substance use, premature sex, and rule-breaking behavior in adolescence.

2.) Parents with a personal history of adolescent misbehavior and parents with older adolescents who misbehave may presume that their child will follow a similar path. Children whose parents and older siblings engage in drug or alcohol use, delinquency, or early sexual activity are, in fact, more likely to engage in these behaviors themselves. Genetics play a powerful role in addictions, risk-taking, and impulsive behaviors. In addition, children whose family members engage in substance use have easier access to drugs and alcohol themselves. Finally, parents and older siblings are powerful role models who teach their children, through example, what is and is not acceptable behavior.

3.) Parents’ negative expectations become self-fulfilling prophecies. Some parents convey, whether subtly or overtly, that drug use, drinking, and sex are as much an inevitable part of adolescence as menarche and chest hair. These parents may be less likely to set firm limits with their children and may not impose consistent consequences for engaging in misbehavior. Perhaps the children of these parents are more likely to internalize their parents’ negative expectations and engage in misbehavior.

So, in addition to genetics and social learning, stereotypes and negative expectations play a powerful role in shaping children’s behavior. The same phenomenon, I’m afraid, is present between therapist and patient (minus the genetics, of course). Stereotypes and negative expectations play a powerful role in bad psychotherapy. There are many unsubstantiated theories of psychopathology that, when espoused by therapists and used in “treatment,” can easily become self-fulfilling prophecies. Here are a few examples:

1.) A therapist presumes that a teenager’s depression is the result of family dysfunction. In order to give the patient a sense of autonomy and protect his confidentiality, the therapist does not involve the family and instead focuses exclusively on the patient. Sessions are spent discussing the problems in the patient’s relationship with his parents. Meanwhile, the parents are growing increasingly worried about their son’s frequent crying, social withdrawal, angry outbursts, and declining school performance. The patient tells his parents that his depression is their fault. Mother blames father for working too much and not spending enough time with the patient. Father blames mother for coddling the patient. The parents’ marriage becomes strained, and the younger brother begins to act out as well.

2.) A therapist asserts that a patient suffering from anorexia nervosa or substance abuse will recover “when she wants to” or “when she’s ready.” The therapist then waits to see signs of “readiness” before pursuing aggressive intervention. Meanwhile, the patient is in the grips of a powerfully self-rewarding, self-perpetuating cycle of starvation or substance abuse and is thus rendered, by virtue of the illness, unable to “choose” recovery. The patient’s symptoms do not abate. Thus, the therapist continues to espouse the belief that the patient is not ready to choose recovery. The patient does not improve, and she concludes that she was not ready for treatment. Now, in addition to her life-threatening and agonizing symptoms, she is carrying around a massive load of guilt, self-blame, and probably blame from her loved ones as well, who don’t understand why she won’t choose recovery. Her symptoms worsen.

3.) A therapist presumes that a patient’s symptoms are the result of a grave trauma, although the patient does not report a history of trauma and there is no other evidence to suggest trauma. Therapy focuses on uncovering this trauma in order to resolve the patient’s symptoms. The therapist asks leading questions in order to confirm her hypothesis that the patient has been abused. The patient, who trusts the therapist and believes in her methods, develops a false memory of abuse. The patient continues to struggle with her symptoms. The therapist tells the patient that she must unravel the roots of her problems, and that it will take many years for her to recover. It does.

4.) A therapist presumes that a patient’s eating disorder is the result of over-controlling parents or relentless boundary violations. The patient is told that, in order to recover, she must break free from her parents’ tyranny and set boundaries for herself. The patient wants desperately to recover but struggles with restrictive eating and drastic weight loss. The therapist helps the patient explore various events of her childhood which supposedly demonstrate parental over-control (“My dad wouldn’t let me wear short skirts to school!”) or boundary violations (“My mom read my diary when I was 13!”). The patient recalls more and more of these types of incidents and discusses them in therapy while she continues to starve and lose weight. Meanwhile, her parents are doing everything in their power to ensure that she eats more: they force her to attend family meals, they pack her lunch for her, they cook for her. These “controlling” behaviors provide more grist for the therapy mill. Eventually, at the therapist’s encouragement, the patient moves out of her parents’ house, gets her own apartment, and stops coming to therapy. The therapist assumes that, released from her overbearing parents, the patient has addressed the root of her illness and has recovered. She has not.

These theories perpetuate themselves, and some practitioners cling to them like religious dogma. Like religious zealots, they latch onto evidence that confirms their belief, and they disregard any evidence to the contrary. They view every patient through the lens of their theory and structure their treatment accordingly. When your only tool is a hammer, everything looks like a nail.

Unless you have suffered from a mental illness, it is difficult to imagine how much it crushes your spirit, distorts your thoughts, warps your perception of reality, and alters your behavior. Unless you have sought therapy yourself, you may not realize just how vulnerable you are, especially as an adolescent or young adult, when you are sitting on the therapist’s couch with all of those distorted thoughts and feelings and perceptions. You are absolutely miserable, and you can’t stand feeling this way any more. The therapist is the expert, the savior, the one who will rescue you from your despair. She comes to know you better than anyone else in your life, and you are certain that she has your best interest in mind. You tell her your deepest secrets, you listen, you trust her, and you do whatever she says you need to do.

My point here is not to overly-dramatize the therapeutic relationship, because I think my description is actually quite realistic. My point is to convey just how harmful stereotypes, negative expectations, and unsubstantiated theories of mental illness can be. Bad therapy is not just ineffective – it has the potential to be every bit as harmful as a surgical error.

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5 Responses to The Power of Expectations

  1. Carrie says:

    Dr. Ravin,

    Thanks for blogging about this. I think #2 and #4 pretty much sum up my early experinces in therapy.

    I was thrilled (in a subdued, geeky sort of way) to learn that there was an actual name for this kind of error in logic: hindsight bias. I blogged about it here: http://ed-bites.blogspot.com/2009/07/hindsight-bias.html

    I don’t know if you’ve seen this blog, but if you haven’t- and you have at least a marginal tolerance for cussing- check out http://www.fxckfeelings.com I think you’d like it!

  2. M. says:

    Dear Dr. Ravin,

    Thank you for saying these things out loud.

    You’re my new hero.

    M.

  3. Polprav says:

    Hello from Russia!
    Can I quote a post “No teme” in your blog with the link to you?

  4. Joanna says:

    Thank you for this site and your blog! When I realized a year ago that my college aged daughter had an eating disorder I turned to the school counseling office who told us they could not treat someone with an active eating disorder and then to our in-network mental health benefits who gave us a choice of 4 therapists in the city she attends school. The therapist she saw spent months working with her trying to discover the past trauma she must have experienced while she lost more weight and got progressively worse (only to conclude there was no history of trauma). Her therapist would not have any contact with us even though my husband and I requested it and my daughter agreed to release information. This did not make intuitive sense to me; she was not making any progress; no one at school knew about her struggles and we were her main support yet we were not included in her treatment or even contacted about how poorly she was doing. Once school was out we did have her do more intensive treatment at a center specializing in ED and she now sees a therapist who primarily treats ED and she is doing better. The information you are providing in your posts is so helpful and makes so much sense. I have a friend who is a therapist tell me that her ED is “not about food, but about control”. I am rambling here but I have to wonder how mental health providers can treat patients with ED’s without being aware of new research in the field? Your blog should be manditory reading for them.

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