Why does Neddy Merrill only talk with women?

Depending on how one reads the story "The Swimmer," there could be several reasons why in his cross-suburbia swim Neddy speaks only with women, never with men. If one reads it with the ending in mind and assumes that the swimmer is really Neddy in the days when he has lost his home, his wife and children, and his social and financial status, then perhaps he only speaks with women because women historically have been the ones to distribute charity in the community toward those who are down and out. Even though at least two of the women he speaks to are unkind to him, presumably their male counterparts would have had even less patience with the former neighbor and friend who has become an alcoholic and beggar. 

If, on the other hand, one reads the story as Neddy's dream, Neddy may sense subconsciously that women will be more supportive and cooperative, or that women will be more likely to give his ego the strokes he is looking for. Women are less threatening to him than men, and so he populates his dream with women in the speaking roles while men are the ones who mock him (the drivers on route 424), expel him from the community (the lifeguards), and rebuff him at the bar (the bartender). 

Finally, if one reads the story as allegory or metaphor, women represent the two things that motivate Neddy: social standing and sexual conquest. As the ones who tend to be the organizers of social gatherings (Lucinda, for example, keeps the Christmas list and Grace Bizwanger is the one who invites her various vendors to her parties), women are the best symbols for social status. Shirley Adams, whom Neddy feels confident will "surely" always be open to his advances, is the symbol of sexual conquest. The men in the story represent the more mundane aspects of life, not the parts that Neddy really cares about. In fact, the men, when they play much of a role at all, represent things that impede Neddy in his pursuits. 

Depending on one's interpretation of the story, Neddy may speak only to women because they are the ones who would be most charitable to a man who has fallen on hard times; because they are less threatening to Neddy's ego; or because they symbolize social standing and sexual conquest, Neddy's two driving motivations. 

What are paraphilias? |

Background

A paraphilia can be centered on a particular object (animals, clothing, etc.) or on a particular act (inflicting pain, exhibitionism, etc.). A paraphilia is characterized by a preoccupation with the object or behavior to the point of dependence on that object or behavior for sexual gratification. Most paraphilias are much more common in men than in women.

Paraphilias are divided into three categories: sexual arousal and preference for nonhuman objects (as in fetishes and transvestism); sexual arousal and a preference for situations that involve suffering and humiliation (such as in sadism and masochism); and sexual arousal and preference for non-consenting partners, behaviors that include exhibitionism and voyeurism.

Specific Types of Paraphilia

Fetishism
. Fetishism involves sexual urges associated with nonliving, or inanimate, objects, including clothing items.

Frotteurism . Frotteurism is characterized by a man rubbing his genitals against a non-consenting, unfamiliar person.

Pedophilia
. Pedophilia is characterized by fantasies or behaviors that involve sexual activity with a child.

Sadomasochism
. Sexual masochism is a paraphilia in which one incorporates his or her sexual urges into suffering to achieve sexual excitement and climax. Sexual sadism involves persistent fantasies in which sexual excitement results from inflicting suffering on a sexual partner. Extreme sadism may involve illegal activities such as rape, torture, and murder.

Transvestism . Transvestism refers to the practice of dressing in clothes associated with the opposite sex to produce or enhance sexual arousal. Note that transvestic disorder only occurs when an individual's cross-dressing causes distress.

Voyeurism . Voyeurism involves achieving sexual arousal by observing an unsuspecting and non-consenting person who is undressing or unclothed or engaged in sexual activity. The voyeur does not seek contact with the person that he or she is observing.

Other paraphilias. Some paraphilias are relatively rare, and include apotemnophilia (sexual attraction to amputations), coprophilia and urophilia (sexual excitement derived from contact with human waste), zoophilia (sexual attraction to nonhuman animals), and necrophilia (sexual attraction to corpses).

Symptoms

A person with paraphilias is distinguished by the insistence and relative exclusivity with which his or her sexual gratification focuses on the acts or objects in question. For many, orgasm is not possible without the paraphilic act or object. Such individuals often have difficulty developing personal and sexual relationships with others and frequently exhibit compulsive behavior. Although it is not known for certain what causes paraphilia, some experts have theorized that paraphilias may develop in response to childhood trauma, such as sexual abuse.

Screening and Diagnosis

The American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders
lists two basic criteria for diagnosing paraphilia: one, the unusual sexual behavior should occur over a period of six months and, two, the sexual behavior causes a clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The second criterion differs for some disorders. For pedophilia, voyeurism, exhibitionism, and frotteurism, the diagnosis is formulated if acting out on these urges or if the urge itself causes a significant distress or interpersonal difficulty. For sadism, a diagnosis is made if these urges involve a non-consenting person. For the other paraphilias, a diagnosis is made when the sexual behavior, urges, or fantasies cause substantial distress or disability in important areas of life.

Treatment and Therapy

Most cases of paraphilia are treated with counseling and therapy in an effort to help patients modify their behavior. Research suggests that cognitive-behavioral models are especially effective in treating persons with paraphilias. Group therapy involves breaking through the denial associated with paraphilias by surrounding the affected person with other people who share their disorder. Once they begin to admit that they have a sexual deviation, a therapist can address individual issues, such as past sexual abuse, that may have led to the disorder. Many physicians and therapists refer persons with paraphilias to twelve-step programs designed for sexual addicts. The programs incorporate cognitive restructuring with social support to increase awareness of the problem.

Also used in treatment are drugs called antiandrogens, which drastically lower testosterone levels in men temporarily. These medications help to decrease compulsiveness and reduce deviant sexual fantasies. In some cases, hormones such as medroxyprogesterone acetate (Depo-Provera) and cyproterone acetate (Androcur) are prescribed for persons who exhibit dangerous sexual behavior. These medications work by reducing one’s sex drive. Antidepressants such as fluoxetine (Prozac) work in a similar manner but have not been shown to effectively target sexual fantasies.

Bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington: APA, 2013. Print.

Bhugra, D. “Paraphilias across Cultures: Contexts and Controversies.” Journal of Sex Research 47.2–3 (2010): 242–315. Print.

Bradford, John M. W., and A. G. Ahmed, eds. Sexual Deviation: Assessment and Treatment. Philadelphia: Elsevier, June 2014. Digital file.

Laws, R. D., and W. T. O’Donohue, eds. Sexual Deviance: Theory, Assessment, and Treatment. 2nd ed. New York: Guilford, 2008. Print.

Lehmiller, Justin J. The Psychology of Human Sexuality. Malden: Wiley, 2014. Print.

Wilson, Glenn, ed. Variant Sexuality. New York: Routledge, 2014. Digital file.

What are natural treatments for osteoporosis?

Introduction

Many factors are known or suspected to accelerate the rate of bone loss. These
factors include smoking, alcohol, low calcium intake, lack of exercise, various
medications, and several illnesses. Excessive consumption of vitamin A may also
increase the risk of osteoporosis, and rapid weight loss may
increase the risk in postmenopausal women. Raw-food vegetarians are also likely to
have significant bone thinning.

In general, women are far more prone to osteoporosis than men. For this reason,
the following discussion focuses almost entirely on women.

Hormone
replacement therapy prevents or reverses osteoporosis in
women. However, long-term use of hormone replacement therapy has been found to be
unsafe, so conventional medical treatment for osteoporosis in women centers mainly
on drugs in the bisphosphonate family, including Fosamax (taken with calcium and
vitamin D).

Exercise, especially weight-bearing exercise, almost certainly helps strengthen
bone (although the evidence for this is weaker than one might expect). Minimal
evidence suggests that the Chinese exercise Tai Chi may
also provide some benefit.

Principal Proposed Natural Treatments

There is good evidence that people with osteoporosis, or who are at risk for it,
should take calcium and vitamin D supplements regardless of what other treatments
they may be using. Substances called isoflavones found in soy and other plants may
be helpful for osteoporosis (and for general menopausal symptoms). Vitamin K and a
newer supplement called strontium ranelate have also shown promise. A
semisynthetic isoflavone called ipriflavone has shown considerable promise for
osteoporosis, but safety concerns have decreased its popularity.

Calcium and vitamin D. Calcium is necessary to build and maintain
bone. Humans need vitamin D too, as the body cannot absorb calcium without it.
Many people do not get enough calcium in their daily diet. Although the body can
manufacture vitamin D when exposed to the sun, supplemental vitamin D may be
necessary because of the common use of sunscreen.

According to most studies, calcium supplements (especially as
calcium citrate, and taken with vitamin D) appear to be modestly
helpful in slowing bone loss in postmenopausal women. Contrary to some reports,
milk does appear to be a useful source of calcium for this purpose. Any
improvements in bone density rapidly disappear once the supplements are stopped.
People who ensure that they continue calcium use may do better than those who
forget from time to time. Vitamin D without calcium, however, does not appear to
offer more than minimal bone-protective benefits for the elderly.

The effect of calcium and vitamin D supplementation in any form is relatively minor and may not be strong enough to reduce the rate of osteoporotic fractures. A large study of more than three thousand postmenopausal women age sixty-five to seventy-one years found that three years of daily supplementation with calcium and vitamin D was not associated with a significant reduction in the incidence of fractures. The use of calcium supplements early in life might prevent problems later, especially when children also engage in physical exercise; however, study results are somewhat contradictory.

One study found benefits for elderly men using a calcium- and vitamin D-fortified milk product. However, there are some concerns that excessive calcium intake could raise the risk of prostate cancer in men.

Vitamin D and calcium taken together may also have a modestly protective effect against the severe bone loss caused by corticosteroid drugs such as prednisone. Certain other supplements may enhance the effects of calcium and vitamin D. One study found that adding various trace minerals (zinc at 15 milligrams [mg], copper at 2.5 mg, and manganese at 5 mg) produced further improvement. However, copper by itself may not be helpful.

There is some evidence that essential fatty acids may also enhance the effectiveness of calcium. In one study, sixty-five postmenopausal women were given calcium with either placebo or a combination of omega-6 fatty acids (from evening primrose oil) and omega-3 fatty acids (from fish oil) for eighteen months. At the end of the study period, the group receiving essential fatty acids had higher bone density and fewer fractures than the placebo group. In contrast to this, however, a similar twelve-month double-blind trial of forty-two postmenopausal women found no benefit from essential fatty acids. The explanation for the discrepancy may lie in the differences among the women studied. The first study involved women living in nursing homes, while the second studied healthier women living on their own. The second group of women may have been better nourished and already receiving sufficient essential fatty acids in their diet. Vitamin K may also enhance the effect of calcium.

Vitamin D may offer another benefit for osteoporosis in the elderly: Most, though not all, studies have found that vitamin D supplementation improves balance in the elderly (especially women) and reduces the risk of falling. Because the most common adverse consequence of osteoporosis is a fracture caused by a fall, this could offer a meaningful benefit. Also, there is weak, preliminary evidence that calcium supplementation in healthy, postmenopausal women may slightly increase the risk of cardiovascular events, such as myocardial infarction.

Genistein and other isoflavones. Soy contains substances called
isoflavones that produce effects in the body somewhat
similar to the effects of estrogen. (For this reason, they are called
phytoestrogens.) Although study results are not entirely
consistent, growing evidence suggests that genistein and
other isoflavones can (like estrogen) help prevent bone loss.

For example, in a one-year, double-blind, placebo-controlled study, ninety women age forty-seven to fifty-seven were given genistein at a dose of 54 mg per day or standard hormone replacement therapy (HRT) or placebo. The results showed that genistein prevented bone loss in the back and hip to approximately the same extent as HRT. No adverse effects on the uterus or breast were seen. A subsequent two-year double-blind study of 389 postmenopausal women with mild bone loss found that 54 mg of genistein plus calcium and vitamin D improved bone density to a greater extent than did calcium and vitamin D alone. However, a fairly high percentage of participants given genistein experienced substantial digestive distress.

In a one-year, double-blind, placebo-controlled study of 203 postmenopausal Chinese women, the use of soy isoflavones at a dose of 80 mg daily had mildly positive protective effects on bone mass in the hip. This supplement contained 46.4 percent daidzein, 38.8 percent glycetein, and 14.7 percent genistein.

Another study evaluated an isoflavone supplement made from red clover (containing 6 mg biochanin A, 16 mg formononetin, 1 mg genistein, and 0.5 mg daidzein daily). In this one-year, double-blind, placebo-controlled study of 205 people, the use of red clover isoflavones significantly reduced loss of bone in the lumbar spine. Benefits were also seen in a one-year, double-blind, placebo-controlled study using an extract made from the soy product tofu.

However, it is not clear that the consumption of foods rich in isoflavones offers the same benefits. For example, in placebo-controlled study involving 237 healthy women in the early stages of menopause, the consumption of isoflavone-enriched foods (providing an average of 110 mg isoflavone daily) for one year had no effect on bone density or metabolism.

The effect of isoflavones on bone may be more complex than that of
estrogen. Bone is always undergoing two opposite processes
at once: bone breakdown and bone formation. Estrogen acts on the first of these
processes by inhibiting bone breakdown. Isoflavones may affect both sides of the
equation at once: inhibiting bone breakdown, while at the same time enhancing new
bone formation.

In about one of three people, intestinal bacteria convert some soy isoflavones into a substance called equol. Isoflavones may have a greater bone-protecting effect in such equol producers.

Strontium. Growing evidence indicates that the mineral
strontium (as strontium ranelate) is effective as an aid in
the treatment of osteoporosis. The best and largest study on strontium was a
double-blind, placebo-controlled study of 1,649 postmenopausal women with
osteoporosis. In this three-year study, a dose of strontium ranelate at 2 grams
(g) daily significantly increased bone density in the spine and hip and
significantly decreased the rate of vertebral fractures.

While some treatments for osteoporosis act to increase bone formation and others act to decrease bone breakdown, some evidence suggests that strontium ranelate has a dual effect, providing both these benefits at once. There is one major caveat, however. All major controlled clinical trials of strontium ranelate have involved some of the same researchers. Entirely independent confirmation is needed. It is not clear to what extent the “ranelate” portion of strontium ranelate is necessary for this benefit, or whether other strontium salts would work too. (The strontium used in these studies is not the same as the radioactive strontium that was such a concern during the decades of above-ground atomic testing in the mid-twentieth century.)

Vitamin K. Increasing, but inconsistent, evidence indicates that
vitamin
K may help prevent osteoporosis. It may work by reducing bone
breakdown, rather than by enhancing bone formation.

Perhaps the best evidence for a beneficial effect comes from a three-year, double-blind, placebo-controlled trial of 181 women. Participants, all postmenopausal women between the ages of fifty and sixty years, were divided into three groups: placebo, calcium plus vitamin D plus magnesium, or calcium plus vitamin D plus magnesium plus vitamin K (at a dose of 1 g daily). Researchers monitored bone loss by using a standard dual-energy X-ray absorptiometry bone density scan. The results showed that the study participants using vitamin K with the other nutrients did not lose as much bone as those in the other two groups. However, another placebo-controlled trial involving 452 older men and women with normal levels of calcium and vitamin D failed to demonstrate any beneficial effects of 500 micrograms per day of vitamin K supplementation on bone health over a three-year period.

Ipriflavone. Ipriflavone is a semisynthetic
variation of soy isoflavones. Ipriflavone appears to help prevent osteoporosis by
interfering with bone breakdown. Estrogen works in much the same way, but
ipriflavonedoes not appear to produce estrogenic effects anywhere else in the body
other than in bone. For this reason, it probably does not increase the risk of
breast or uterine cancer. However, it also does not reduce the hot flashes, night
sweats, mood changes, or vaginal dryness of menopause. In addition, it may cause
health risks of its own.

Numerous double-blind, placebo-controlled studies involving more than seventeen hundred participants have examined the effects of ipriflavone on various forms of osteoporosis. Overall, it appears that ipriflavone can stop the progression of osteoporosis and perhaps reverse it to some extent. For example, a two-year double-blind study followed 198 postmenopausal women who had evidence of bone loss. At the end of the study, there was a gain in bone density of 1 percent in the ipriflavone group compared to a loss of 0.7 percent in the placebo group.

Conversely, the largest and longest study of ipriflavone found no benefit. In this three-year trial of 474 postmenopausal women, no differences in extent of osteoporosis were seen between ipriflavone and placebo groups. However, for reasons that are not clear, the researchers in this study gave women only 500 mg of calcium daily. All other major studies of ipriflavone gave participants 1,000 mg of calcium daily. It is possible that ipriflavone requires the higher dose of calcium to work properly.

Ipriflavone may also be helpful for preventing osteoporosis in women who are
taking Lupron or corticosteroids, medications that accelerate bone loss.
(However, the combined use of ipriflavone and drugs that suppress the immune
system, such as corticosteroids, presents risks.)

There is some evidence that combining ipriflavone with estrogen may improve benefits against osteoporosis. However, it is not known whether such combinations increase or decrease the other benefits and adverse effects of estrogen-replacement therapy. Finally, for reasons that are not clear, ipriflavone appears to be able to reduce pain in osteoporosis-related fractures.

Other Proposed Natural Treatments

It is often said that magnesium supplements are helpful for strong bones, but there is only minimal evidence to support this claim. It has been suggested (though with little meaningful supporting evidence) that the typical American diet causes the body to become acidic, and that this in turn leads to bone loss. One study tested potassium citrate as a treatment for bone loss, in the belief that this supplement would counteract this hypothesized diet-related acidity. The results in this one-year study of 161 postmenopausal women indicated that potassium citrate reduced bone loss to a greater extent than did the placebo (potassium chloride). This study had numerous problems in design, analysis, and reporting, so it does not necessarily show anything about dietary “acidity.” It may, however, indicate that the citrate part of potassium citrate has some bone-protective effects. If this is true, it could in turn explain why calcium citrate has, in some studies, proven more effective for treating or preventing osteoporosis than other forms of calcium.

Observational studies hint that higher levels of homocysteine might increase the
risk of osteoporosis. Vitamins B12, B6, and folate are known
to reduce homocysteine levels. On this basis, supplementation with these vitamins
has been proposed for preventing or mitigating the effects of osteoporosis. One
double-blind study found weak evidence that supplemental folate and
vitamin B12 (known to reduce homocysteine) might reduce risk of
osteoporotic fractures in people who had had a stroke. However, two other studies
failed to find that the use of mixed B-vitamins had any positive effect on bone
density or chemical markers of bone turnover.

Some evidence suggests that the hormone dehydroepiandrosterone (DHEA) may be helpful for preventing or treating osteoporosis, especially in postmenopausal women older than age seventy years. Also, one study found weak evidence that DHEA might be helpful for preventing the osteoporosis that sometimes develops in women with anorexia nervosa.

Chinese studies suggest that the herb Epimedium brevicornum has phytoestrogenic effects and, on this basis, may be helpful for preventing bone loss. (E. brevicornum is related, but not identical, to E. sagittatum, otherwise known as horny goat weed.)

Preliminary evidence suggests that black tea may help protect against
osteoporosis. Similarly weak evidence hints that the herb black cohosh
might help prevent osteoporosis. Although it has long been stated that high
phosphorus intake from the consumption of soft drinks might lead to osteoporosis,
there is no solid evidence for this claim. Elevated intake of phosphorus may help
prevent osteoporosis. The reason is that bone contains both calcium and
phosphate.

According to one preliminary study, but not another, boron may be helpful for
preventing osteoporosis. However, there are some concerns that boron
supplements may raise levels of the body’s own estrogen, especially in women on
estrogen-replacement therapy, and therefore might present an increased risk of
cancer. To increase boron intake, one should eat more fruits and vegetables.

One study widely advertised as showing that silicon is helpful for osteoporosis actually failed to show much of anything. Extremely weak evidence hints at possible benefit for osteoporosis through the use of royal jelly.

Although it has long been believed that consuming too much protein (especially animal-based protein) increases the risk of osteoporosis, the balance of available evidence suggests the reverse: If anything, high intake of protein appears to help strengthen bone. One study found that calcium supplements may do a better job of strengthening bones in people with relatively high protein intake than in those with lower intake.

It has been suggested both that water fluoridation helps prevent osteoporosis
and also that it causes the condition; on balance, however, the evidence suggests
that it does neither. Another study failed to find arginine supplements helpful
for enhancing bone density.

Progesterone. Many books promote the idea that natural
progesterone prevents or even reduces osteoporosis. In this
case, the term “natural” means the same progesterone found in the body. It is
still made synthetically, but it is called natural progesterone to distinguish it
from its chemical cousins known as progestins. Generally, prescription
“progesterone” is actually a progestin.

The progesterone-osteoporosis story began with test-tube and other preliminary studies suggesting that progesterone or progestins can stimulate the activity of cells that build bone. Subsequently, a poorly designed and uncontrolled study (actually, a series of case histories from one physician’s practice) purportedly demonstrated that progesterone cream can slow or even reverse osteoporosis.

However, a one-year double-blind trial of 102 women using either progesterone cream (providing 20 mg progesterone daily) or placebo cream, along with calcium and multivitamins, found no evidence of any improvements in bone density attributable to progesterone. Furthermore, in a three-year study of 875 women, combination treatment with estrogen and oral progesterone was no more effective for osteoporosis than estrogen alone.

Estriol. Some alternative medicine practitioners have popularized
the use of a special form of estrogen called estriol,
claiming that, unlike standard estrogen, it does not increase the risk of cancer.
However, this claim is unfounded.

Controlled trials performed in Japan have found that estriol helps prevent bone loss in menopausal women, although one small study found no benefit. However, like other forms of estrogen, oral estriol stimulates the growth of uterine tissue. This leads to a risk of uterine cancer.

In a placebo-controlled study of 1,110 women, greater uterine tissue stimulation was seen among women given estriol orally (1 to 2 mg daily) than among those given placebo. Another large study found that oral estriol increased the risk of uterine cancer. In another study of 48 women given estriol at a dose of 1 mg twice daily, uterine tissue stimulation was seen in the majority of cases.

In contrast, a twelve-month double-blind trial of oral estriol (2 mg daily) in sixty-eight Japanese women found no effect on the uterus. It may be that the high levels of soy in the Japanese diet altered the results. Additionally, test-tube studies suggest that estriol is just as likely to cause breast cancer as any other form of estrogen. Women who use estriol should consider it like any other form of estrogen.

Herbs and Supplements to Use with Caution

While the evidence is not yet strong, some research suggests that excessive intake of vitamin A may increase the risk of osteoporosis. Also, herbs and supplements may interact adversely with drugs used to treat osteoporosis, so persons should be cautious when considering the use of herbs and supplements.

Bibliography

Atkinson, C., et al. “The Effects of Phytoestrogen Isoflavones on Bone Density in Women.” American Journal of Clinical Nutrition 79 (2004): 326-333.

Avenell, A., et al. “Oral Vitamin D3 and Calcium for Secondary Prevention of Low-Trauma Fractures in Elderly People.” The Lancet 365 (2005): 1621-1628.

Barger-Lux, M. J., et al. “Calcium Supplementation Does Not Augment Bone Gain in Young Women Consuming Diets Moderately Low in Calcium.” Journal of Nutrition 135 (2005): 2362-2366.

Bischoff-Ferrari, H. A., and B. Dawson-Hughes. “Where Do We Stand on Vitamin D?” Bone 41, suppl. 1 (2007): S13-S-19.

Bolland, M. J., et al. “Vascular Events in Healthy Older Women Receiving Calcium Supplementation.” British Medical Journal 336 (2008): 262-266.

Bolton-Smith, C., et al. “Two-Year Randomized Controlled Trial of Vitamin K1 (Phylloquinone) and Vitamin D3 plus Calcium on the Bone Health of Older Women.” Journal of Bone and Mineral Research 22 (2007): 509-519.

Booth, S. L., et al. “Effect of Vitamin K Supplementation on Bone Loss in Elderly Men and Women.” Journal of Clinical Endocrinology and Metabolism 93 (2008): 1217-1223.

Brink, E., et al. “Long-term Consumption of Isoflavone-Enriched Foods Does Not Affect Bone Mineral Density, Bone Metabolism, or Hormonal Status in Early Postmenopausal Women.” American Journal of Clinical Nutrition 87 (2008): 761-770.

Carpenter, T. O., et al. “A Randomized Controlled Study of Effects of Dietary Magnesium Oxide Supplementation on Bone Mineral Content in Healthy Girls.” Journal of Clinical Endocrinology and Metabolism 91 (2006): 4866-4872.

Cockayne, S., et al. “Vitamin K and the Prevention of Fractures.” Archives of Internal Medicine 166 (2006): 1256-1261.

Courteix, D., et al. “Cumulative Effects of Calcium Supplementation and Physical Activity on Bone Accretion in Premenarchal Children.” International Journal of Sports Medicine 26 (2005): 332-338.

Daly, R. M., S. Bass, and C. Nowson. “Long-Term Effects of Calcium-Vitamin-D(3)-Fortified Milk on Bone Geometry and Strength in Older Men.” Bone 39 (2006): 946-953.

Dodiuk-Gad, R. P., et al. “Sustained Effect of Short-Term Calcium Supplementation on Bone Mass in Adolescent Girls with Low Calcium Intake.” American Journal of Clinical Nutrition 81 (2005): 168-174.

Fontana, L., et al. “Low Bone Mass in Subjects on a Long-Term Raw Vegetarian Diet.” Archives of Internal Medicine 165 (2005): 684-689.

Harwood, R. H., et al. “A Randomised, Controlled Comparison of Different Calcium and Vitamin D Supplementation Regimens in Elderly Women After Hip Fracture.” Age and Ageing 33 (2004): 45-51.

Herrmann, M., et al. “The Effect of B-Vitamins on Biochemical Bone Turnover Markers and Bone Mineral Density in Osteoporotic Patients.” Clinical Chemistry and Laboratory Medicine 45 (2007): 1785-1792.

Jankowski, C. M., et al. “Effects of Dehydroepiandrosterone Replacement Therapy on Bone Mineral Density in Older Adults.” Journal of Clinical Endocrinology and Metabolism 91 (2006): 2986-2993.

Kelley, G. A., and K. S. Kelley. “Exercise and Bone Mineral Density at the Femoral Neck in Postmenopausal Women.” American Journal of Obstetrics and Gynecology 194 (2006): 760-767.

Lanou, A. J., et al. “Calcium, Dairy Products, and Bone Health in Children and Young Adults: A Reevaluation of the Evidence.” Pediatrics 115 (2005): 736-743.

Martyn-St. James, M., and S. Carroll. “High-Intensity Resistance Training and Postmenopausal Bone Loss.” Osteoporosis International 17 (2006): 1225-1240.

Reid, I. R., et al. “Randomized Controlled Trial of Calcium in Healthy Older Women.” American Journal of Medicine 119 (2006): 777-785.

Von Mühlen, D., et al. “Effect of Dehydroepiandrosterone Supplementation on Bone Mineral Density, Bone Markers, and Body Composition in Older Adults.” Osteoporosis International 19 (2008): 699-707.

Wayne, P. M., et al. “The Effects of Tai Chi on Bone Mineral Density in Postmenopausal Women.” Archives of Physical Medicine and Rehabilitation 88 (2007): 673-680.

What are children's issues with separation and divorce?

Introduction

At the beginning of the twenty-first century, every year more than one million children in the United States experienced the divorce of their parents, according to the U.S. Bureau of the Census. It was estimated that about 40 percent of all children would experience divorce before they reached eighteen years of age.

Most studies regarding children’s issues in divorce conceptualize the separation and divorce process as a stressful family transition to which children must adapt. These studies focus on the specific factors that children face in divorce, the protective factors that may assist them, and the range of outcomes experienced by all children of divorce. Divorce is not a discrete event but a process that begins with the specific sociological aspects in place in a particular family prior to the marital separation and continues through the divorce to the adjustment period afterward. Children are involved throughout the process and may experience a range of psychological, social, academic, and health issues as a result of the divorce. Children from different ethnic and cultural groups may experience different rates of parental divorce and remarriage and variations in specific effects.

The study of children’s issues before, during, and after separation and divorce is controversial because of the different social and political viewpoints held by family life scholars. Some scholars believe that children need two-parent homes to achieve optimum development and that divorce and single-parent families have a negative impact on the institution of the family, resulting in many social problems. Other scholars believe that it is possible for children to develop well in different family structures, including single-parent families and stepfamilies. These scholars suggest that divorce may resolve home problems and ultimately benefit the development of children by creating more healthy and positive home environments. The differences among scholars can lead to alternative interpretations of research results and very different reports of the implications of research findings for families and society.

Perspectives on Children’s Adjustment

American psychologist E. Mavis Hetherington identified five perspectives that help to explain the relationship between divorce and children’s adjustment to it. The individual risk and vulnerability perspective proposes that some parents may have characteristics or psychological problems that make it more likely that they will experience divorce. These individual factors will also have an impact on the way the parents handle the divorce and the consequences of divorce for their children. On the other hand, children have individual characteristics that may safeguard them from the negative consequences of divorce or increase their vulnerability to negative outcomes.

The family composition perspective predicts that any family structure other than the two-biological-parent family may be related to increased problems for children. Research concerning the father’s absence after divorce is related to this perspective.

The stress and socioeconomic disadvantage viewpoint notes that divorce may lead to an increased number of stressful life events, including new roles, change of residence, loss of social networks, child-care problems, conflict with the former spouse, and decreases in family finances. Children and parents may be affected negatively by these events. Research on the frequent financial problems of former spouses, especially custodial mothers, originates from this viewpoint.

The parental distress perspective indicates that tremendous variability exists in how individual parents handle all the issues and difficulties involved in divorce. Some parents are able to manage the events well and continue to provide consistent parenting to their children; other parents experience a noted deterioration in their parenting skills following divorce.

Finally, the family process viewpoint recognizes that divorced families may demonstrate disruptions in family relationships and interactions, having an impact on such processes as child discipline or child rearing. Hetherington suggests that the five perspectives complement each other and form a transactional model for understanding the impact of divorce on children.

Sociologist Paul R. Amato of Pennsylvania State University proposed a divorce-stress-adjustment model that incorporates the multiple perspectives noted by Hetherington into three factors: mediators, moderators, and adjustment. Amato noted that the divorce process may begin months or years prior to separation with a cycle involving overt conflict between the parents, attempts to renegotiate the relationship, or avoidance and denial of the problems. It is not unusual to note increased behavior problems in children at this early stage that reflect the marital discord.

Individual differences, however, may be noted between children. Some children may experience significant distress as a result of parental conflict prior to separation, so that the level of distress diminishes after marital separation. Other children may be unaware of the marital difficulties until the separation occurs, precipitating significant distress at that point. Children experience mediators or stressors that continue throughout the divorce process. They may include a decline in parental support and effective control, loss of contact with one parent, continuing conflict between parents, and economic decline.

In Amato’s model, moderators or protective factors interact with the stressors throughout the process to determine the ultimate adjustment of the child. Moderators include individual resources (such as coping skills), interpersonal resources (such as extended family support), structural resources (such as school programs and services), and demographic characteristics (age, gender, race, ethnicity, and culture) that combine to determine how a particular child will respond to the stressors of divorce. Adjustment refers to the time and intensity of psychological, behavioral, and health problems for children before they adapt to the new roles required of them by the divorce.

Most Common Issues for Children

Research on the effects of divorce on children between 1960 and 2000 consistently showed that children whose parents had divorced scored lower than children whose parents remained married on several outcome measures. Amato analyzed the research several times and noted small but statistically significant differences on measures such as conduct, academic achievement, psychological adjustment, self-concept, social competence, and long-term health. These effects continue even though more children are experiencing family divorce, the social stigma of divorce appears to have diminished, and support services for children of divorce have increased. A few studies indicate that divorce has positive results for some children, especially when divorce ends chronic high-conflict marriages that had created negative home environments, but the number of children in this type of situation is relatively low.

Research conducted by sociologist Yongmin Sun at Ohio State University confirmed that divorce is a multistage process, beginning before separation. Sun studied 10,088 students and compared the results of 798 students (8 percent) whose parents divorced over a two-year period to students whose parents did not divorce. He found that families in the predisruption phase, the period when the family is still intact before disruption of the marriage, show evidence of different family processes than do families that remain intact. The families that eventually divorced experienced deterioration in relationships between the parents and the children at least one year before the divorce. These parents did fewer things with their children, had lower expectations for the children, and were not as involved in school issues and events. The children had lower school math and reading scores and exhibited more behavior problems than did children in families that did not experience divorce.

After divorce, children may experience a variety of effects. One major problem for children of divorce is the continuation of preseparation conflict between the parents into the postdivorce period. By the second year after separation, one-third of parent relationships are still conflicted, one-fourth have achieved a cooperative coparenting relationship, and one-third are disconnected and do not interact about parenting. Continuing conflict is a problem because exposure to angry exchanges and fighting is itself a stressor for children. Conflict may also result in decreases in the quality of the parent-child relationship, including less consistent discipline, less demonstration of affection toward the child, emotional dependence on the child, less ability to control parental anger, and using the child as a cocombatant in disputes with the former spouse. Conflict that involves the child directly (such as fights in the child’s presence or arguments that focus on the child or child rearing or include the child in the dispute) is most harmful to the child. In general, the greater the degree of conflict between the parents, the more likely it is that the child will experience psychological distress. Interventions that diminish conflict are likely to have beneficial results for children of divorce.

Many children have diminished contact with their fathers following the divorce. Studies indicate that when the mother has primary physical custody, more than one-fourth of all children report that they did not see their father in the last year and only about one-fourth saw their father at least weekly. More than half of fathers are not involved at all in making decisions about their children, and half did not pay any child support during the previous year. Fathers who have joint custody, live near their children, or had stronger emotional relations with their children prior to the divorce are more likely to have regular contact after the divorce.

The effects of divorce on children often continue over time, although the immediate emotional disruption and behavioral problems may be resolved within the first two years. Interview research by Judith Wallerstein with children of divorce over a twenty-five-year period suggested that even as children grow into adulthood, there is a continuing impact of divorce on their attitudes and behaviors toward relationships and marriage. Other researchers note a variety of effects later in life, including an increased probability of divorce for the children of divorce.

Bibliography

Amato, Paul R. “The Consequences of Divorce for Adults and Children.” Journal of Marriage and the Family 62 (2000): 1269–87. Print.

Baker, Amy J. L., and Paul R. Fine. Surviving Parental Alienation: A Journey of Hope and Healing. Lanham: Rowman & Littlefield, 2014. Print.

Emery, Robert E. Marriage, Divorce, and Children’s Adjustment. 2nd ed. Thousand Oaks: Sage, 1999. Print.

Hetherington, E. Mavis, ed. Coping with Divorce, Single Parenting, and Remarriage: A Risk and Resiliency Perspective. Mahwah: Lawrence Erlbaum, 1999. Print.

O'Hagan, Kieran. Filicide-Suicide: The Killing of Children in the Context of Separations, Divorce and Custody Disputes. New York: Palgrave Macmillan, 2014. Print.

Teyber, Edward. Helping Children Cope with Divorce. Rev. ed. San Francisco: Jossey-Bass, 2001. Print.

Thompson, Ross A., and Paul R. Amato, eds. The Postdivorce Family: Children, Parenting, and Society. Thousand Oaks: Sage, 1999. Print.

Wallerstein, Judith S., and Joan B. Kelly. Surviving the Breakup. 1980. New York: Basic Books, 1996. Print.

Wallerstein, Judith S., Julia Lewis, and Sandra Blakeslee. The Unexpected Legacy of Divorce: A Twenty-five Year Landmark Study. New York: Hyperion, 2002. Print.

Wallerstein, Judith, Julia Lewis, and Sherrin Packer Rosenthal. "Mothers and Their Children after Divorce: Report from a 25-Year Longitudinal Study." Psychoanalytic Psychology 30.2 (2013): 167–84. Print.

What is the relationship between punishment and social psychology?

Introduction

Punishment can be defined as an action taken based on a person’s undesired behavior. It is intended to prevent future occurrence of the unwanted behavior by changing how the person behaves. It is a social mechanism used to help ensure the balanced functioning of a family, group, organization, or a society.

There are two main elements to punishment. First, appropriate behavior is arbitrary; it is determined by communal agreement regarding right and wrong behavior. Punishment attempts to foster and ensure what the group has determined to be appropriate, moral behavior. Second, punishment symbolizes power. The French philosopher Michel Foucault argued that punishment should be understood as an expression of power because, without the power to punish a person behaving in an undesirable manner, chaos could occur.

When a member of any social unit, small or large, goes against the group’s accepted norms, it disrupts the unit. To regain balance or homeostasis, action may be needed, and a member of the social unit may punish the wrongdoer. Punishment may take the form of making some kind of amends. This could range from a token act to exile (temporary or permanent) or even to death.

A Brief History

One of the earliest records of punishments levied by a society can be found in a legal code developed in Babylon in about 2000 BCE, during the reign of Hammurabi, which listed corrective measures for wrongdoing. The Mosaic law recorded in the Pentateuch of the Old Testament is another early set of codes. Near the end of the first century CE, corporal punishment was increasingly applied to slaves and lower-class citizens, while punishments for higher-class citizens generally took the form of compensation.

During the reign of the Roman emperor Justinian in the sixth century, an attempt was made to match the severity of punishment to the level of the offense. More than a century later, laws became increasingly localized, although they generally followed the dictates of the Roman Catholic Church. Many of these laws were centralized during the reign of Charlemagne.

When William the Conqueror became king of England following the Norman invasion, he centralized power around himself as monarch. Any wrongdoing therefore became a crime against the king. He established the process of trial by ordeal to address those who violated the law, who were known as enemies of the king. Much of the punishment, official and unofficial, was directed at the offenders’ bodies, through forms of torture.

It was not until the age of reason that major changes began to occur. With the development of social contracts, crimes were considered to have been committed against society, and people began to be viewed as rational beings able to make rational choices. It was during this period that the classical school offered new foundations of punishment as represented in the writings of Cesare Beccaria and Jeremy Bentham. These scholars believed that a person had free will and could make a rational choice whether to commit an offense. People made their choices by weighing the pleasure of the action against the punishment for it. Therefore, the punishment should fit the crime; be proportionate to the violation; be uniform and equal; be certain, swift, and severe; and deter and prevent.

Over the centuries, scholars have continued to debate what is effective punishment. For if punishment does not bring about the desired changes, then it does not serve its purpose.

Philosophies of Punishment

Most punishments are designed to prevent wrongdoers from repeating their acts and to deter people from committing undesired acts. There are four main philosophies of punishment. They are retribution (just deserts), deterrence, rehabilitation, and control (incapacitation).

Retribution has often been linked to revenge, taking an eye for an eye. Under this philosophy of punishment, justice is served if the punishment is equivalent to the wrongdoing: offenders get what they deserve (their just deserts). This has been the basis of much legal code.

As a philosophy of punishment, deterrence attempts to either restrict certain behaviors or encourage people to avoid them. Punishments aimed at deterring crime are designed to cause people to lose as much or more from committing an undesired behavior as they stand to gain from the behavior. Such punishments should cause a person to chose not to engage in the undesired behavior. However, punishment should not be excessive, as this might have negative overall results.

Rehabilitation seeks to change the offender so the person will not repeat the act. Under this philosophy, it is believed that the offender suffers from some sort of needs or deficiencies, and these deficiencies need to be addressed for the individual to change. Punishment should be individualized to address the offender’s needs and deficiencies.

Control is based on the rationale that if the offender is incapacitated, the person cannot repeat the unacceptable behavior. Although establishing control over an offender does not keep the individual from desiring to commit an undesirable act, it effectively contains the person and prevents the individual from acting inappropriately. Control may take the form of restricting the person’s movement or simply supervising the person.

Moral Development

An important consideration of punishment is whether the offender knows right from wrong. The process of learning what society has deemed right and wrong requires the moral development of the individual. This learning process is described differently by various psychological schools.

The psychoanalytic school describes this as a child learning to act in a manner in which the child will experience positive feelings and avoid negative feelings. Sigmund Freud focused on the development of the child’s personality during the learning process, whereas Erik H. Erikson examined how children internalize the teachings of both parents to win and keep their love.

The cognitive school is represented by the theorists Jean Piaget and Lawrence Kohlberg. Piaget presented his theory that as children develop, they gain respect for rules and justice. The development process begins in a premoral period, a period in which children have little awareness of rules but simply act in a way that gives them pleasure. Then at about school age, children begin to develop an awareness of rules that they regard as absolute. They believe that either an act is right or wrong; they also believe in imminent justice, or that any wrong act will be punished in some way.

In the final stage in Piaget’s process of cognitive development, children begin to surrender the absoluteness of rules for a more relative understanding of the nature of rules. This change comes from an awareness that rules are arbitrary social agreements and on occasion can be challenged, as rules should serve human needs. As a result, rules can be violated to serve the needs of a person. After experiencing and seeing others violate rules and go unpunished, children begin to accept the idea of reciprocal punishment, which is a more rehabilitative form of punishment.

Kohlberg developed on Piaget’s theory by extending the development process. He created a three-level development process in which each level had two stages. This development process was unidirectional. Once a person has moved to a higher level of development, the individual could not regress to a lower level.

Kohlberg’s first level was preconventional morality. At this level, a child follows rules to avoid punishment and to receive rewards. The punishment determines how bad an act is: The more severe the punishment, the worse the wrong. A child conforms to rules to seek rewards and self-satisfaction.

In conventional morality, a child seeks approval of others and tries to avoid shame. A child begins to experience understanding of others (empathy) and to conform to rules out of a desire to cooperate with others.

In postconventional morality, the third level, the child’s moral reasoning is based on a broader understanding of justice and right and wrong. Sometimes the child’s understanding of right and wrong is in conflict with the established rules and therefore justifies challenging rules. In the second stage within the third level, universal justice, the child is able to transcend any conflict through an ideal reasoning process.

Learning

Behaviorists and cognitivists have applied principles of reinforcement and punishment to change behavior. Both reinforcement and punishment can be positive or negative and are used to condition a person to act within the range of acceptable or desired behavior.

Reinforcement is a reward people receive for performing the desired or appropriate behavior. It is intended to increase the possibility of people’s adopting the behavior. A positive reward is receiving something the person wants and a negative reward is having something removed that the person does not want. In identifying appropriate reinforcers, an individual’s personal economy—the value a person places on an item or an action—must be determined. Individualizing reinforcers makes them more effective in accomplishing the goal of change.

Punishment is used to prevent or change undesired behavior and to decrease the possibility of it recurring. A positive punishment is the gaining of something unwanted, and a negative punishment is the loss of something wanted. Either punishment is undesirable for the recipient.

A major difference between behavorists, such as B. F. Skinner, and cognitivists, such as Albert Bandura, is the cognitive factor of learning. Skinner did not accept that humans have free will but believed that their actions are environmentally determined. Bandura argued the value of observation and modeling. He proposed that a person could learn by observing the rewards and punishments another person received for behavior. Some studies, including that by Robert E. Larzelere and his associates, have suggested that a more effective disciplinary response can be produced by combining reasoning and punishment rather than using reasoning alone.

Bibliography

Castro, Nicolas. Psychology of Punishment: New Research. Hauppage: Nova, 2013. Digital file.

Cusac, Anne-Marie. Cruel and Unusual: The Culture of Punishment in America. New Haven: Yale UP, 2010. Print.

Horne, Christine. The Rewards of Punishment: A Relational Theory of Norm Enforcement. Stanford: Stanford UP, 2009. Print.

Larzelere, Robert E., et al. “Punishment Enhances Reasoning’s Effectiveness as a Disciplinary Response to Toddlers.” Journal of Marriage and the Family 60 (1998): 388–430. Print.

Miltenberger, Raymond G. Behavior Modification: Principles and Procedures. 5th ed. Belmont: Wadsworth, 2012. Print.

Molm, Linda D. “Is Punishment Effective: Coercive Strategies in Social Exchange.” Social Psychology Quarterly 57.2 (1994): 75–94. Print.

Oswald, Margit E., Steffen Bieneck, and Jorg Hupfeld-Heinemann, eds. Social Psychology of Punishment of Crime. Malden: Wiley, 2009. Print.

Russo, Jennifer P., and Nicholas M. Palmetti. Psychology of Punishment. New York: Nova, 2011. Digital file.

Sparks, Richard, and Jonathan Simon. The SAGE Handbook of Punishment and Society. Los Angeles: SAGE, 2013. Digital file.

What is couples therapy? |

Introduction

Traditionally, marriage
vows have represented pledges of mutual love and enduring commitment. Since the 1960s, however, marital relationships have changed dramatically. In fact, while more than 90 percent of the United States population will marry at least once in their lifetime, the US Census Bureau estimated in 2009 that approximately 40 percent of all first marriages and approximately 60 percent of all second marriages end in divorce. Moreover, while the average first marriage in the United States will last approximately eight years, second marriages typically endure for approximately the same time period at 8.5 years. It appears that a repetitive pattern of marriage, distress, and divorce has become commonplace. Such a cycle often results in considerable pain and psychological turmoil for the couple, their family, and their friends. These statistics dramatically indicate the need for effective ways to help couples examine and reapproach their relationships before deciding whether to terminate them.

Interpersonal relationships are a highly complex yet important area of study and investigation. The decision to marry (or at least to commit to a serious intimate relationship) is clearly one of the most significant choices many people make in their lives. Fortunately, advances in couples therapy have led to increased knowledge about interpersonal relationships and methods for improving relationship satisfaction. These advances have been documented in the scientific literature, and they extend to the treatment of cohabitating partners, premarital couples, remarried partners, married and premarital same-sex couples, separating or divorced couples, and stepfamilies. Moreover, couples-based treatment programs have shown effectiveness in the treatment of depression, anxiety disorders, domestic violence, sexual dysfunction, and a host of other problems.

Communication and Conflict Resolution

Often, partners who seek couples therapy or counseling have problems in two areas: communication and conflict resolution. These are the two major difficulties that most often lead to divorce. It has been shown that communication skills differentiate satisfied and dissatisfied couples more powerfully than any other factor. Indeed, communication difficulties are the most frequently cited complaint among partners reporting relationship distress.

Psychologist John M. Gottman, in Marital Interaction: Experimental Investigations (1979) and the cowritten A Couple’s Guide to Communication (1976), is one of many researchers who have highlighted the importance of communication problems within distressed relationships. Many characteristic differences between distressed and satisfied couples have been noted. Partners in distressed couples often misperceive well-intended statements from their partners, whereas satisfied couples are more likely to rate well-intended messages as positive; distressed partners also engage in fewer rewarding exchanges and more frequent punishing interactions than nondistressed couples. A partner in a distressed relationship is more immediately reactive to perceived negative behavior exhibited by his or her partner. There is generally a greater emphasis on negative communication strategies between distressed partners.

Distressed couples appear to be generally unskilled at generating positive change in their relationship. Gottman also reported that distressed couples are often ineffectual in their attempts to resolve conflicts. Whereas nondistressed couples employ “validation loops” during problem-solving exercises (one partner states the conflict and the other partner expresses agreement or support), distressed couples typically enter into repetitive, cross-complaining loops. These loops can be described as an interactional sequence wherein both individuals describe areas of dissatisfaction within the relationship yet fail to attend to their partners’ issues. Moreover, as one spouse initiates aversive control tactics, the other spouse will typically reciprocate with similar behavior.

Therapy Formats

Couples therapy attempts to alleviate distress, resolve conflicts, improve daily functioning, and prevent problems via an intensive focus on the couple as a unit and on each partner as an individual. Couples therapists are faced with a variety of choices regarding treatment format and therapeutic approach. Individual therapy focuses treatment on only one of the partners. Although generally discouraged by most practitioners, individual treatment of one partner can provide greater opportunities for the client to focus on his or her own thoughts, feelings, problems, and behaviors. Clients may feel less hesitant in sharing some details they would not want a spouse to hear, and individual treatment may encourage the client to take greater personal responsibility for problems and successes. In general, these advantages are outweighed by the difficulties encountered when treating relationship problems without both partners being present. In particular, interpersonal interactions are complex phenomena that need to be evaluated and treated with both partners present.

Concurrent therapy involves both partners being seen in treatment separately, either by the same therapist or by two separate but collaborating therapists. Advantages of the concurrent format include greater individual attention and opportunities to develop strategies to improve relationship skills by teaching each partner those techniques separately. Concurrent treatment, however, does not allow the therapist(s) to evaluate and treat the nature of the interpersonal difficulties with both partners present in the same room.

Conjoint format, on the other hand, involves both partners simultaneously in the therapy session. Conjoint treatment is widely used and generally recommended because it focuses intensively on the quality of the relationship, promotes dialogue between the couple, and can attend to the needs and goals of each partner as well as the needs and goals of the couple. The history of conjoint marital therapy begins, ironically, with Sigmund Freud’s failures in this area. He believed firmly that it was counterproductive and dangerous for a therapist ever to treat more than one member of the same family. In fact, in 1912, after attempting to provide services simultaneously to a husband and wife, Freud concluded that he was at a complete loss about how to treat relationship problems within a couple. He also added that he had little faith in individual therapy for them.

Conjoint treatment is designed to focus intensively on the relationship to effect specific therapeutic change for that particular couple. Interventions can be tailor-made for the couple seeking treatment, regardless of the nature of the problem the couple describes (such as sexual relations, child rearing, or household responsibilities). Moreover, couples are constantly engaged in direct dialogue, which can foster improved understanding and resolution of conflict. As compared with other approaches, conjoint marital therapy can focus on each of the specific needs and goals of the individual couple.

Group couples treatment programs have received increased attention and have shown very good to excellent treatment success. Advantages of group treatment for couples include opportunities for direct assessment and intervention of the relationship within a setting that promotes greater opportunity for feedback and suggestions from other couples experiencing similar difficulties. In fact, group therapy may promote positive expectations through witnessing improvements among other couples as well as fostering a sense of cohesiveness among couples within the group. In the group format, each partner has the opportunity to develop improved communication and conflict resolution approaches by learning relationship skills via interaction with the therapist(s), his or her spouse, and other group members. In addition, the cost of individual, concurrent, and conjoint therapy, in terms of time as well as dollars, has prompted several researchers and clinicians to recommend group couples therapy.

Therapeutic Approaches

There are numerous approaches to the treatment of relationship problems practiced in the United States. Psychodynamic therapy focuses attention on the unconscious needs and issues raised during an individual’s childhood. Phenomenological therapists focus on the here-and-now experiences of being in a relationship and have developed a variety of creative therapeutic techniques. Systems therapists view interpersonal problems as being maintained by the nature of the relationship structure, patterns of communication, and family roles and rules.

Behavioral marital therapy, however, is the most thoroughly investigated approach within the couples therapy field. Starting from a focus on operant conditioning (a type of learning in which behaviors are altered primarily by the consequences that follow them— reinforcement or punishment), behavioral marital therapy includes a wide range of assessment and treatment strategies. The underlying assumption that best differentiates behavioral treatments for distressed couples from other approaches is that the two partners are viewed as ineffectual in their attempts to satisfy each other. Thus, the goal of therapy is to improve relationship satisfaction by creating a supportive environment in which the skills can be acquired. Behavioral marital therapy incorporates strategies designed to improve daily interactions, communication patterns, and problem-solving abilities and to examine and modify unreasonable expectations and faulty thinking styles.

Behavioral-Exchange Strategies

Psychologists Philip and Marcy Bornstein, in their book Marital Therapy: A Behavioral-Communications Approach (1986), described a sequential five-step procedure in the treatment of relationship dysfunction. These steps include intake interviewing, behavioral exchange strategies, communication skills acquisition, training in problem solving, and maintenance and generalization of treatment gains.

Intake interviewing is designed to accomplish three primary goals: development of a working relationship with the therapist, collection of assessment information, and implementation of initial therapeutic regimens. Because spouses entering treatment have often spent months, if not years, in conflict and distress, the intake procedure attempts to provide a unique opportunity to influence and assess the couple’s relationship immediately. Because distressed couples often devote a considerable amount of time thinking about and engaging in discordant interpersonal interactions, it naturally follows that they will attempt to engage in unpleasant interactions during initial sessions. Information about current difficulties and concerns is clearly valuable, but improved communication skills and positive interactions appear to be of even greater merit early in treatment. Thus, couples are discouraged from engaging in cross-complaining loops and are encouraged to develop skills and implement homework procedures designed to enhance the relationship.

Skill Training

Building a positive working relationship between partners is viewed as essential in couples treatment programs. During training in behavioral exchange strategies, couples are aided in specifying and pinpointing behaviors that tend to promote increased harmony in their relationship. Couples engage in contracting and compromise activities to disrupt the downward spiral of their distressed relationship.

Training in communication skills focuses on practicing the basics of communication (such as respect, understanding, and sensitivity) and of positive principles of communication (timeliness, marital manners, specification, and “mind reading”), improving nonverbal behaviors, and learning “molecular” verbal behaviors (such as assertiveness and constructive agreement). Improved communication styles are fostered via a direct, active approach designed to identify, reinforce, and rehearse desirable patterns of interactions. Clients are generally provided with specific instructions and “practice periods” during sessions in which partners are encouraged to begin improving their interactional styles. It is common for these sessions to be audiotaped or videotaped to give couples specific feedback regarding their communication style.

Training in problem solving is intended to teach clients to negotiate and resolve conflicts in a mutually beneficial manner. Conflict resolution training focuses on learning, practicing, and experiencing effective problem-solving approaches. Couples receive specific instruction on systematic problem-solving approaches and are given homework assignments designed to improve problem-solving skills. Because the value of couples therapy lies in the improvement, maintenance, and use of positive interaction styles over time and across situations, treatment often aims to promote constructive procedures after the termination of active treatment. Thus, people are taught that it is generally easier to change oneself than one’s partner, that positive interaction styles may be forgotten or unlearned if these strategies are not regularly practiced, and that new positive interactions can continue to develop in a variety of settings even as treatment ends.

Comparative Research

To highlight further the utility and effectiveness of behavioral-communications relationship therapy, Philip Bornstein, Laurie Wilson, and Gregory L. Wilson conducted an empirical investigation in 1988 comparing conjoint and behavioral-communications group therapy and group behavioral-communications therapies to a waiting-list control group (couples who were asked to wait two months prior to beginning treatment). Fifteen distressed couples were randomly assigned to experimental conditions and offered eight sessions of couples therapy. At the conclusion of treatment (as well as six months later), the couples in active treatment revealed significant alleviation of relationship distress. The conjoint and group couples revealed similar levels of improvement in communication skills, problem-solving abilities, and general relationship satisfaction. The waiting-list couples, on the other hand, revealed no improvement while they waited for treatment, indicating that relationship distress does not tend to improve simply as the result of the passage of time.

Prevention and Disorders

Another line of couples research has focused on the utility of premarital intervention and distress- and divorce-prevention programs. Unlike treatment programs, prevention programs intervene before the development of relationship distress. Prevention efforts are focused on the future and typically involve the training of specific skills that are viewed as useful in preventing relationship distress. Three major approaches to premarital intervention include the Minnesota Couples Communication Program, Bernard Guerney’s relationship enhancement approach, and the Premarital Relationship Enhancement Program. Research is generally supportive of the effectiveness of these programs in helping partners learn useful skills that translate into improved relationships for at least three to eight years following the program. In addition, some evidence indicates that the alarming divorce rate in the United States can be decreased if partners participate in prevention programs before marriage; prevention programs that emphasize communication and conflict-resolution skills seem most advantageous.

Improving Treatment

Researchers and clinicians have witnessed large increases in the numbers of couples seeking treatment from therapists. The Bureau of Labor Statistics reported the employment rate for marriage and family therapists to grow an estimated 29 percent from 2012 to 2022, which is a much faster-than-average growth rate than is predicted in other occupations. As the demand for couples treatment increases, more time and effort is devoted to improving treatment methods. The behavioral approach has been shown to be highly effective in reducing relationship distress and preventing divorce; however, many believe that cognitive components such as causal attributions and expectations are strongly related to satisfaction in the relationship. Moreover, it has been argued that dysfunctional cognitions may interfere with both the establishment and maintenance of positive behavior change. Evidence has prompted some researchers and practitioners to advocate a more systematic inclusion of strategies of cognitive behavior therapy within the behavioral marital therapy framework. Specifically, it is possible that the combination of cognitive and behavioral approaches will demonstrate increased utility if the two treatments are presented together in a singular, integrated treatment intervention. Such treatment would afford couples the opportunity to benefit from either one or both of the complementary approaches, depending on their own unique needs, at any time during the course of treatment. Moreover, such an integration of cognitive and behavioral tactics would parallel effective approaches already employed with depressed or anxious clients.

Bibliography

Beck, Aaron T. Love Is Never Enough. New York: Harper & Row, 1989. Print.

Bornstein, Philip H., and Marcy T. Bornstein. Marital Therapy: A Behavioral-Communications Approach. New York: Pergamon, 1986. Print.

Fruzzetti, Alan E. The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, and Validation. Oakland: New Harbinger, 2006. Print.

Gottman, John M., et al. A Couple’s Guide to Communication. Champaign: Research Press, 1979. Print.

Gottman, Julie, and John M. Gottman. Ten Principles for Doing Effective Couples Therapy. New York: Norton, 2014. Print.

Gurman, A. S. Casebook of Marital Therapy. New York: Guilford, 1985. Print.

Gurman, A. S., and D. P. Kniskern. Handbook of Family Therapy. Vol. 2. New York: Brunner/Mazel, 1991. Print.

Hendrix, Harville. Getting the Love You Want: A Guide for Couples. New York: Holt, 2008. Print.

Hewison, David, Christopher Clulow, and Harriet Drake. Couple Therapy for Depression: A Clinician's Guide to Integrative Practice. New York: Oxford UP, 2014. Print.

Jacobson, Neil S., and A. S. Gurman, eds. Clinical Handbook of Couple Therapy. 4th ed. New York: Guilford, 2008. Print.

Jacobson, Neil S., and Gayla Margolin. Marital Therapy: Strategies Based on Social Learning and Behavior Exchange Principles. New York: Brunner/Mazel, 1979. Print.

Pitta, Patricia. Solving Modern Family Dilemmas: An Assimilative Therapy Model. New York: Routledge, 2014. Print.

What is acne? |

Causes and Symptoms

Many skin disorders are grouped together as acne. The two most common are acne vulgaris and acne rosacea. Other acne diseases include neonatal acne and infantile acne, seen respectively in newborn babies and infants. Drug acne is a consequence of the administration of such medications as corticosteroids, iodides, bromides, anticonvulsants, lithium preparations, and oral contraceptives, to name some of the more common agents that are sometimes involved in acne outbreaks. Pomade acne and acne cosmetica are associated with the use of greasy or sensitizing substances on the skin, such as hair oil, suntan lotions, cosmetics, soap, and shampoo. They may be the sole cause of acne in some individuals or may aggravate existing outbreaks of acne vulgaris. Occupational acne, as the name implies, is associated with exposure to skin irritants in the workplace. Chemicals, waxes, greases, and other substances may be involved. Acné excoriée des jeunes filles, or acne in young girls, is thought to be associated with emotional distress. In spite of the name, it can occur in boys as well. Two forms of acne are seen in young women. One is pyoderma faciale, a skin eruption that always occurs
on the face. The other is perioral dermatitis (peri, around; ora, the mouth), characterized by redness, pimples, and pustules. Acne conglobata is a rare but severe skin disorder that is seen in men between the ages of eighteen and thirty.

In acne vulgaris, a disruption occurs in the normal activity of the pilosebaceous units of the dermis, the layer of the skin that contains the blood vessels, nerves and nerve endings, glands, and hair follicles. Ordinarily, the sebaceous glands secrete sebum into the hair follicles, where it travels up hair shafts and onto the outer surface of the skin, to maintain proper hydration of the hair and skin and prevent loss of moisture. In acne vulgaris, the amount of sebum increases greatly, and the hair shaft that allows it to escape becomes plugged, holding in the sebum.

Acne vulgaris usually occurs during
puberty and is the result of some of the hormones released at that time to help the child become an adult. One of the major hormones is testosterone, an androgen (andros, man or manhood; gen, generating or causing), so called because it brings about bodily changes that convert a boy into a man. In boys, testosterone and other male hormones cause sexual organs to mature. Hair begins to grow on the chest and face and in pubic areas and armpits. Musculature is increased, and the larynx (voice box) is enlarged, so the voice deepens. In males, testosterone and other male hormones are produced primarily in the testicles. In girls, estrogens and other female hormones are released during puberty, directing the passage of the child from girlhood to womanhood. Testosterone is also produced, mostly in the ovaries and the adrenal glands.

In both sexes during puberty, testosterone is taken up by the pilosebaceous glands and converted to dihydrotestosterone, a substance that causes an increase in the size of the glands and increased secretion of the fatty substance sebum into hair follicles. At the same time, a process occurs that closes off the hair follicle, allowing sebum, keratin, and other matter to collect. This process is called intrafollicular hyperkeratosis (from intra, inside, follicular, referring to the follicle, hyper, excessive, and keratosis, production of keratin). Keratin buildup creates a plug that blocks the follicle opening and permits the accumulation of sebum, causing the formation of a closed comedo. As more and more material collects, the comedo becomes visible as a white-capped pimple, or whitehead. Closed comedones are the precursors of the papules, pustules, nodules, and cysts characteristic of acne vulgaris. Papula means “pimple,” a pustule is a pimple containing pus, nodus means a
small knot, and the word “cyst” comes from kystis, meaning “bladder,” or in this case a sac filled with semisolid material. Sometimes cysts are referred to generically as sebaceous cysts, but the material inside is usually keratin.

Another lesion in acne vulgaris, called an open comedo, occurs when a sac in the outer layer of the skin fills with keratin, sebum, and other matter. Unlike the closed comedo, it is open to the surface of the skin and the material inside appears black—hence the term “blackhead.” Blackheads are unsightly, make the skin look dirty, and suggest that they are caused by bad hygienic habits. This is not true, but exactly why the material in the sac turns black is not fully understood. Some believe that the natural skin pigment melanin is involved.

Blackheads are usually easily managed and rarely become inflamed. It is the closed comedo, or whitehead, that causes the disfiguring lesions of acne vulgaris. As the closed comedo fills with keratin and sebum, colonies of bacteria, usually Propionibacterium acnes, develop at the site. The bacteria secrete enzymes that break down the sebum, forming free fatty acids that inflame and irritate the follicle wall. With inflammation, white blood cells are drawn to the area to fight off the bacteria.

The comedo enlarges with further accumulation of white blood cells, keratin, and sebum until the follicle wall ruptures, spreading inflammation. If the inflammation is close to the surface of the skin, the lesion will usually be a pustule. If the inflammation is deeper, a larger papule, nodule, or cyst may form.

Clothing, cosmetics, and other factors may exacerbate acne vulgaris. Headbands, chin straps, and other items can cause trauma that ruptures closed comedones and spreads infection. Ingredients in cosmetics, soaps, and other preparations used on the skin can contribute to the formation of comedones in acne vulgaris. Lanolin, petrolatum, laurel alcohol, and oleic acid are among the chemicals commonly found in skin creams, cosmetics, soaps, shampoos, and other preparations applied to the skin. They have been shown to aggravate existing acne in some people and to bring on acne eruptions in others.

It was long thought that fatty foods—such as chocolate, ice cream, desserts, and peanut butter—contributed to acne, perhaps because teenagers eat so much of them. This theory has been largely discarded. Except for specific allergic sensitivities, foods do not appear to cause or in any other way affect the eruptions of acne vulgaris.

Cases of acne vulgaris are classified as mild, moderate, or severe. In mild and moderate acne vulgaris, the number of lesions ranges from a few to many, appearing regularly or sporadically and occurring mostly in the top layer of the skin. Consequently, these cases are sometimes called “superficial acne.” In severe cases, the acne lesions are deep, extending down into the skin, and characterized by inflamed papules and pustules.

Superficial acne, or mild-to-moderate acne vulgaris, is easily managed with the therapies available. The teenager goes through a year to two dealing with “zits.” The problem may be irritating and may cause inconvenience and discomfort, but it is common among teenagers, and little lasting harm is done. With time and treatment, the skin clears and the problem is over.

With deep or severe acne, however, the condition can be devastating, physically and psychologically. In these cases, the lesions may come in massive eruptions that cover the face and extend to the neck, chest, and back. The lesions can be large and deep, frequently causing disfiguring pits and craters that become lifelong scars. The victims of severe acne can suffer profound psychological damage. The disease strikes at a time when most teenagers are especially concerned with being gregarious, popular, and well liked. The chronic, constant disfigurement effectively isolates the individual, however, often making him or her unwilling to risk social contact.

The other common form of acne is acne rosacea, so called because of the “rosy” color that appears on the face. Unlike acne vulgaris, it rarely strikes people under thirty years of age and is not characterized by comedones, although papules and pustules are common. It is predominantly seen in women, although its most serious manifestations are seen in men. The cause of acne rosacea is unknown, but it is more likely to strike people with fair complexions. It is usually limited to the center of the face, but eruptions may occur on other parts of the body.

Acne rosacea is progressive; that is, it gets worse as the patient grows older. It seems to occur most often in people who have a tendency to redden or blush easily. The blushing, whether it is caused by emotional distress, such as shame or embarrassment, or by heat, food, or drink, may be the precursor of acne rosacea. The individual finds that episodes of blushing last longer and longer until, eventually, the redness becomes permanent. Papules and pustules break out, and surface blood vessels become dilated, causing further redness. As the disease progresses, tissue overgrowth may cause the nose to swell and become red and bulbous. Inflammation may develop in and around the eyes and threaten vision. These severe symptoms occur more often in men than in women.

Treatment and Therapy

The majority of acne patients are treated at home with over-the-counter preparations applied topically (that is, on the skin). For years, many of the agents recommended for acne contained sulfur, and some still do. Sulfur is useful for reducing comedones, but it has been suggested that sulfur by itself may also cause comedones; however, sulfur compounds, such as zinc sulfate, are not suspected of causing comedones. Resorcinol and salicylic acid are commonly included in topical over-the-counter preparations to promote scaling and reduce comedones. Sometimes sulfur, resorcinol, and salicylic acid are used singly, sometimes together, and sometimes combined with topical antiseptics or other agents.

While most patients will be helped by the available over-the-counter agents, many will not respond adequately to such home therapy. These patients must be seen by a doctor, such as a family practitioner or dermatologist. The physician attempts to eliminate existing lesions, prevent the formation of new lesions, destroy microorganisms, relieve inflammation, and prevent the occurrence of cysts, papules, and pustules. If the patient’s skin is oily, the physician may advise washing the face and other affected areas several times a day. This has little effect on the development of comedones, but it may improve the patient’s appearance and self-esteem. The physician will also use medications that are similar to over-the-counter antiacne agents but more powerful. These include drying agents, topical antibiotic preparations, and agents to abrade the skin, such as exfoliants or desquamating (scale-removing) agents.

Various topical antibiotics have been developed for use in acne vulgaris, such as topical tetracycline, clindamycin, and erythromycin. One that is often used is benzoyl peroxide, a topical antibiotic that can penetrate the skin and reach the sites of infection in the hair follicles. It is also a powerful irritant that increases the growth rate of epithelial cells and promotes sloughing, which helps clear the surface of the skin. It is effective in resolving comedones and seems to suppress the release of sebum. Because it has a high potential for skin irritation, benzoyl peroxide must be used carefully. Physicians generally start with the weaker formulations of the drug and increase the strength as tolerance develops.

Vitamin A has been given orally to patients with acne vulgaris in the hope of preventing the formation of comedones. The effective oral dose of the vitamin for this purpose is so high, however, that it could be toxic. Therefore, a topical form of vitamin A was developed called vitamin A acid, retinoic acid, or tretinoin (marketed as Retin A). Applied directly to the skin, it has proved highly beneficial in the treatment of acne vulgaris. It clears comedones from the hair follicles and suppresses the formation of new comedones. It reduces inflammation and facilitates the transdermal (through-the-skin) penetration of medications such as benzoyl peroxide and other topical antibiotics. Like benzoyl peroxide, vitamin A acid can be irritating to the skin, so it must be used carefully. When benzoyl peroxide and vitamin A acid are used in combination in the treatment of acne vulgaris, their therapeutic effectiveness is significantly increased. The physician generally prescribes a morning application of one and an evening application of the other.

When large comedones, pustules, or cysts form, the physician may elect to remove them surgically. The procedure is quite effective in improving appearance, but it does nothing to affect the course of the disease. Furthermore, it demands great skill on the part of the physician to avoid causing damage and irritating the surrounding skin, rupturing the comedo wall, and allowing inflammation to spread. The patient should be advised not to try to duplicate the process at home: Picking at pimples could create open lesions that may take weeks to heal and may produce deep scars. Sometimes, the physician will insert a needle into a deep lesion in order to drain the material from it. Sometimes, the physician tries to avoid surgery by injecting a minute quantity of corticosteroid, such as triamcinolone acetonide, into a deep lesion to reduce its size.

The physician may wish to add the benefits of sunlight to medical therapy. Sunlight helps dry the skin and promotes scaling and clearing of the skin, which is probably why acne improves in summer. The physician may suggest sunbathing, but an overzealous patient could become sunburned or chronically overexposed to the sun, thereby risking skin cancer. The beneficial effects of natural sunlight are not necessarily achievable with a sunlamp and, over a long period of exposure, the ultraviolet light produced by some lamps may actually increase sebum production and promote intrafollicular hyperkeratosis.

About 12 percent of patients with acne vulgaris develop severe or deep acne. In devising a treatment regime for these cases, the physician has many options to help clear the patient’s skin, reduce the number and occurrence of lesions, and prevent the scarring that can disfigure the patient for life. Both the topical medications benzoyl peroxide and vitamin A acid are used, singly and in combination, as well as many other topical preparations. Nevertheless, these patients often also require oral antibiotics to fight their infection from within.

It may take weeks for oral antibiotic therapy to achieve results, and it may even be necessary for the patient to continue the therapy for years. Therefore, the physician looks for an antibiotic that is effective and safe for long-term use. Oral tetracycline is often the physician’s choice because it has been proven effective against Propionibacterium acnes, and it seems to suppress the formation of comedones. Oral tetracycline is usually safe for long-term therapy, and it is economical. Other oral antibiotics used to treat acne vulgaris are erythromycin, clindamycin, and minocycline.

Yet in long-term therapy with any broad-spectrum antibiotic, there is always the possibility that the agent being used will not only kill the offending organism but also destroy “friendly” bacteria that aid in bodily processes and help protect the body from other microorganisms. When this happens, disease-causing pathogens may be allowed to flourish and cause infection. For example, prolonged use of antibiotics in women may allow the growth of a yeastlike fungus, Candida, which can cause vaginitis. Prolonged use of clindamycin may allow the proliferation of Clostridium difficile, which could result in ulcerative colitis, a severe disorder of the lower gastrointestinal tract.

If, for any reason, the physician believes that oral antibiotics are not working or must be discontinued, there are other therapeutic agents and other procedures that may be helpful in treating severe, deep acne vulgaris. One medication that is highly effective, but also potentially very harmful, is isotretinoin. As the name implies, isotretinoin (meaning “similar to tretinoin”) is derived from vitamin A, but it is both more effective and more difficult to use. Unlike the topical vitamin A acid preparations, isotretinoin is taken orally. It is highly effective in inhibiting the function of sebaceous glands and preventing the formation of closed comedones by reducing keratinization, but isotretinoin also produces a wide range of side effects. The majority of these are skin disorders, but the bones and joints, the eyes, and other organs can be affected. Perhaps the most serious adverse effect of isotretinoin is that it can cause severe abnormalities in the fetuses of pregnant women. Therefore, pregnancy is an absolute contraindication for isotretinoin. Before they take this drug, women of childbearing age are checked to ensure that they are not
pregnant. They are advised to use strict contraceptive measures one month before therapy, during the entire course of therapy, and for at least one month after therapy has been discontinued.

Estrogens, female hormones, have been used to treat severe acne in girls and women who are more than sixteen years of age. The aim of this therapy is to counteract the sebum-stimulating activity of circulating testosterone and to reduce the formation of comedones by reducing the amount of sebum produced. Estrogens cannot be used in males because the dose required to reduce sebum production could produce feminizing side effects.

Persistent lesions can be treated with cryotherapy. In this procedure, an extremely cold substance such as dry ice or liquid nitrogen is carefully applied to the lesion. This technique is effective in reducing both small pustules and deeper cysts. For patients whose skin has been deeply scarred by acne, a procedure called dermabrasion, in which the top layer of skin is removed, may help improve the appearance.

Although its cause is unknown, acne rosacea can be treated. The topical antiparasitic drug metronidazole, applied in a cream, and oral broad-spectrum antibiotics such as tetracycline have been found effective. It may be necessary to continue antibiotic therapy for a long period of time, but the treatment is usually effective. Surgery may be required to correct the bulbous nose that sometimes occurs with this condition.

Perspective and Prospects

Most acne vulgaris (about 60 percent) is treated at home. There has been significant improvement in the treatment of mild-to-moderate acne vulgaris, so for most of these patients, the condition can be limited to an annoyance or an inconvenience of the teen years. Only recalcitrant cases of acne vulgaris are seen by physicians. Of those cases treated by doctors, the majority are seen by family physicians, general practitioners, and other primary care workers. Severe acne is usually referred to the dermatologist, who is skilled in the use of the more serious medications and the more exacting techniques that are required in treatment.

For at least 85 percent of those experiencing puberty, acne vulgaris is a fact of life. It is a natural consequence of the hormonal changes that occur at this time. It is not likely that any drugs or techniques will be found to avoid acne in the teenage years, as this would involve tampering with a fundamental growth process. It can be expected, however, that in this condition, as in so many others, progress will continue to be made, and newer, more effective, and safer agents will be developed.

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