Ford, Nixon, and the Decisions We Make

The death of President Gerald Ford has reopened an old debate: Should he have pardoned Nixon for the crimes he committed during the Watergate scandal? The debate has bubbled up in both the blogosphere and in the letters to the editor in most newspapers. It's not necessary for me to provide any links; the debate is everywhere. It got me thinking about decision-making and the guilt we have when our decisions go wrong.

Many of my clients come to me saying, "If only I had done X instead of Y, things would have been better." For example, "If I stayed with my old job, and not taken that new job, I wouldn't have been fired, and I'd be able to pay for my kid's college today. My kids are suffering from my bad decision."

In order to help my clients with their guilt, I teach them about the reality of decision-making. Ford's decision to pardon Nixon is an excellent example. To make the decision, Ford asked himself, "What are the most likely outcomes if I pardon Nixon, and what are the most likely outcomes if I don't? Which outcomes would serve the greater good?" Ford thought that pardoning Nixon would bring the Watergate scandal to a quick end. Nixon deserved to be punished, but resigning in disgrace was enough punishment for him. I'm sure he knew people would disagree with his decision, and that would have political consequences for him.

In contrast, Ford thought, if Nixon were to be prosecuted, the investigation, the trial, and the appeals would drag on for years. There was no guarantee that Nixon would have been convicted. This, too would have political consequences for the Republican Party. Or, if Nixon was convicted, would it be overturned on appeal? So, Ford decided to pardon Nixon, thinking this would serve the greater good.

Today, Ford's critics argue that the country needed Nixon to be tried for his crimes if the country to truly recover from Watergate. They argue that pardoning Nixon increased cynicism about government by showing the powerful were above the law. Some say that the more recent scandals stem from that cynicism. They conclude that all the problems Ford was concerned about were worth it for the country to heal.

The old admonition, "Hindsight is 20-20," is relevant here. But, even in hindsight, notice that time only goes forward. There is no way for us to go back again, and find out what would have happened if Ford hadn't pardoned Nixon. So, we don't really know "what would have happened if...."

Imagine this scenario: Ford doesn't pardon Nixon. There's a long, drawn out, O. J. Simpson-esque trial, and Nixon is found guilty. He appeals, and his conviction is overturned because the jury wasn't impartial. The prosecutor, knowing a lost cause when he sees it, doesn't try Nixon again. How much cynicism would that engender? What would happen then?

At this point in the scenario, I'm overwhelmed by the possibilities. It's impossible to know what would happen next, especially as we become more removed from the original choice. Each choice opens up new choices and new possible outcomes.

OK, so we never have any way of knowing "What would happen if...." Does that mean we can't evaluate our decisions at all? Is there anything like a good or bad decision? Is this another fuzzy-headed liberal way of avoiding consequences? No. We can evaluate our decisions, but we have to change the way we look at them.

First, let me summarize:

1. When me make decisions, we are guessing about future outcomes. We cannot know how every possible decision might turn out.

2. We can never know what would have happened if we made a different choice.

3. All we can ever know is how our choices have affected us and are affecting us. Tomorrow, things might change completely.

4. Past choices continue to affect us. They open up some choices to us and limit others.

It is therefore unrealistic to evaluate a decision as "good" or "bad". Choices don't "work out." Instead, they put us on paths. Those paths may take us to places that are more or less desirable, but until we die, those paths don't end. Instead of asking, "Did I make a good decision?" I should instead ask:

1. Did I make the decision well? Did I consider a range of possible alternatives, consider my values, consult others, and think through my decision carefully? Or, did I just jump into it without any forethought?

2. Am I happy with the path I'm on as a result of my decisions?

Notice the implications here. We can make a decision carefully, and be unhappy with where it took us. In the same way, we can make a decision impulsively, and it takes us to some very good places. Overall, though, if we make our decisions carefully, we have a better chance at being happy with the path we take.

So, when my clients ask, "How could I have been so stupid as to do that?" I teach them it's OK to say, "It seemed like a good idea at the time." Because time only goes forward, we can't go back and change our decisions. However, we can always make more decisions and find better paths for our lives.

President Ford made a decision which may have cost him the presidency. That path must have been a difficult path for him. Personally, I agreed with the choice he made, although for other reasons, I voted against him. I respect him deeply, though. Despite pardoning Nixon, Ford still restored confidence in the presidency. He did it by making other choices throughout his presidency. I'm going to miss him. After the mess Bush has made, we desperately need another Gerald Ford.

Insight and Psychotherapy

Now that Chanukah has passed, my round of parties and events has also passed. Christmas is a pretty boring day for me, so it gives me a chance to catch up on this poor, neglected blog.

There have been several good articles in the New York Times over the last few weeks. This one, entitled, "Sometimes the Why isn't Crucial," caught my attention. The author, Sally Satel, is a psychiatrist. She works in a substance abuse treatment facility and she questions the effectiveness of insight as a psychotherapeutic tool for her. She argues that explaining "why" someone drinks isn't as important as developing resources to resist urges to drink.

Developing insight is the primary vehicle of change for psychoanalysis and related therapies. Freud famously observed, "The child is the father of the man," meaning who we are today comes from our previous experiences. For these insight-based therapies, developing insight means not only explaining why someone has their problem, but also helping them get in touch with the feelings associated with it. Along with the couch, it's a stereotypical view of psychotherapy.

The public is generally unaware that arguments against insight-based therapies dates back many years. Albert Ellis has been arguing this point since the 1950's. In a more recent book titled (as only he can title it), How to Refuse to Make Yourself Miserable about Anything Yes Anything, he says (as only he can say):

Your early childhood experiences and your past conditioning did not originally make you disturbed. You did. (p.70).

Ellis argues that how we think and act in the present is what really matters. He says, speaking of his clients, "Their early thoughts and feelings did not make them anxious today. Rather, their present and continuing dogmas...were really the more direct cause of their current neurosis." (p.70; Emphasis in the the original). So, according to Ellis, we effect emotional and behavioral change by addressing current irrational beliefs, not by uncovering how the beliefs were acquired.

Ellis is not the only one. Behaviorists, such as Joseph Wolpe , also writing in the 1950's, argued that exposure to the feared stimulus was a more effective way of treating phobias than insight-based therapies. Fifty years later, and God knows how many studies, we still treat phobias with exposure-based treatments. The data is conclusive. Insight alone is at best minimally effective in treating phobias or almost any psychological dysfunction.

Satel identifies one reason why insight isn't effective. We have a tendency to distort our memories of life events in an effort to develop a coherent narrative:

What scientists call hindsight bias kicks in when we try to figure out the causal chain of events leading to the current situation. We may well come up with a tidy story but, inevitably, it will contain large swaths of revisionist history. It’s not that we bias ourselves deliberately; it happens because the mind tends to make events in the past appear comprehensible and orderly. We forget the uncertainties that might have beset us as we struggled in real time.

So, how do we develop insight based on "large swaths of revisionist history?" If we're reconstructing our past, an erroneous reconstruction would logically hinder our progress. Is insight important at all?

I think so. Insight has a limited, but important place because it helps us deal with resistance in psychotherapy. To illustrate, here are two vignettes. To guard my clients' privacy, they are composites of several past clients with a little bit of stereotyping mixed in.

First, consider a client who resists going to AA meetings. Normally, the therapist would take this as a sign the client is still denying his alcoholism. Without looking at his past, the therapist's natural tendency would be to confront the client about his denial. However, there is another issue.

The AA meetings remind the client of prayer meetings his family attended while he was a child. The religious sect that sponsored these meetings encouraged physical abuse of children, and the client is still coping with intense feelings of guilt and powerlessness stemming from this. After identifying this source of resistance do you think the client will then jump up and go to AA meetings? Of course not.

Putting the resistance into that context will do two things. It will relieve the client's guilt for not following through with clinical recommendations. Second, giving the client the right to refuse AA and still be respected will help him feel less powerless. Then, the therapist should look for other ways of working on recovery.

The second example involves cognitive therapy for a female client who is unable to trust men. She goes through cycles where she meets a man and falls deeply in love with him. Then, without reason, she becomes extremely jealous. She harasses him, checks on him, and eventually drives him away. She comes into therapy depressed and hopeless about ever having a normal relationship.

Without dealing with this in historical context, cognitive therapy would focus on changing the dysfunctional cognitions the client has about men. The therapist would probably identify the thought, "If my boyfriend were to cheat on me, it would be so awful, I couldn't survive it." Then, the therapist would challenge (a) the probability of cheating; and (b) whether or not her boyfriend's cheating would be survivable. However, each effort to challenge her beliefs is met by "Yes, but...." It is classic resistance behavior.

The "yes, but..." indicates the therapist is arousing anxiety which is itself interfering with therapy. A review of the client's history indicates she grew up in a family where the father had frequent affairs. There were chaotic arguments between the parents each time an affair was uncovered. The mother became increasingly depressed and spent most of her time in bed. After years of chaos, in which the client wound up being a parent to both her mother and her younger siblings, her parents finally divorced. Her mother remained angry and embittered for the rest of her life, insisting that all men are worthless.

So, the client's belief is closer to this: "All men are cheaters and when (not if) my boyfriend cheats on me, it will be awful! I'll turn into my mother and the rest of my life will be ruined." With this historical context, the therapist and client understand the "why" of her behavior. Without that understanding, there is no way to help the client will take the risk of changing her beliefs. The anxiety engendered by being reminded of her childhood is too great. Still, for change to happen, she needs to know that, in the present, she has the resources to deal with loss, rejection, and betrayal, without turning into her mother. Then, she can say, "It would be bad if my boyfriend cheated on me, but I can survive it. The risk is worth it, because it gives me a chance to have a happy, rewarding relationship."

In conclusion, explaining "why" has its place in therapy, but is useless by itself. Good therapy stays in the present, but uses the past as context. Even if the story is distorted, it still has value, providing meaning and motivation for change.

Goal-Setting and Marital Therapy

A recent article by Locke and Latham (2006) in Current Directions in Psychological Science reports on the status of goal-setting theory. I like setting goals in therapy because it's intuitive for most people. I don't have to teach them about irrational ideas, superegos, or schemas. It just makes sense to people to identify their therapeutic goals and how to achieve them. So, I was happy to hear that several obvious implications of goal-setting (e.g., the higher the goal, the better the performance--within limits) have good empirical support.

Much of the article was focused on industrial, not clinical psychology, but they made several observations that I found very relevant. In discussing the interaction of personality traits and goals, they differentiated between a learning orientation and a performance orientation:

The effects of goal setting as a state on the effects of goal orientation as a trait were studied by Seijts, Latham, Tasa, and Latham (2004). People with a learning goal orientation tend to choose tasks in which they can acquire knowledge and skill. Those with a performance goal orientation tend to avoid tasks where others may judge them unfavorably due to possible errors they might make. Hence they tend to choose easy tasks in which they can look good in the eyes of others. Seijts et al. (2004) found that a specific high learning goal (state orientation) is effective in increasing a person's performance regardless of their trait orientation. Performance is highest on a complex task, however, when people have a learning goal orientation and also set a learning goal. In short, the beneficial effect of a learning goal orientation can be attained by inducing it as a state.

If I can parse the academese (It's getting more difficult for me as I get older), this means:

1. People who value learning (a "learning goal orientation") prefer tasks where they can learn things.
2. People who value successful performance (a "performance goal orientation") avoid tasks where they might fail.
3. Performance is highest on complex tasks when the person has set a goal to learn new things and also has a learning goal orientation.

Yes, I know these three points are obvious. However, this is where things start to get interesting:

4. A person with a performance goal orientation will perform particularly badly under situations of high learning pressure.
5. We can induce a learning orientation by setting a goal to learn, rather than to perform.

Think of learning pressure as performance anxiety. When we are extremely anxious about our performance, it interferes with our functioning on goal-directed tasks. Hence, a student may go blank on a test, or a ballplayer (I'll leave out the Boston jokes) might drop an easy ground ball. There are some very good implications for marital therapy here.

When people come in for marital therapy they are in a state of crisis. Usually, they are saying to each other, "If you don't change, I'm leaving." But one of the most complex tasks I know is getting along with other people, especially a spouse. So, the overall goal in marital therapy is to improve how they relate to their spouse, but they are trying to do so under a state of extreme performance anxiety. No wonder marital therapy fails all too often.

Most of my clients don't have a learning orientation. Some have a performance orientation. Others have neither; they just kinda go along with life with very few goals (sometimes I envy them). The key point is that in marital therapy, there is a very high level of learning pressure.
So, the trick is to reduce the performance anxiety and increase the learning orientation. Here's my idea. I'll begin by saying:

In marital therapy our overall goal is to learn new ways of relating to each other. This is a difficult proposition. You only learn by trying, sometimes failing, and sometimes succeeding. Therapy can only work if you make it easy for the other person to try and to fail. Both of you will have to learn to tolerate each other's failures, without berating or attacking the other.

A lot of times one spouse is fed up. I expect that one person will object, saying, "I'm sick of being patient. If I let up on him/her, he/she won't change!" So, to show them the importance of reducing performance anxiety, I'll have the angry spouse do serial sevens while I badger them with, "Hurry up! If you don't get this right, I won't treat you, and your marriage is going to fail. It'll be all your fault because you couldn't do simple arithmetic. Come on! This is easy!" If I can get them laughing about this, it'll make the point. Setting a learning orientation and keeping the performance anxiety down should go a long way towards improving therapy. This will prove to be an interesting experiment.

References

Locke, E. A., Latham, G. P. (2006). New directions in goal-setting theory. Current Directions in Psychological Science, 15, 265-268.

Seijts, G.H., Latham, G.P., Tasa, K., & Latham, B.W. (2004). Goal setting and goal orientation: An integration of two different yet related literatures. Academy of Management Journal, 47, 227–239.

'Tis the Season of Greed and Gluttony

With Thanksgiving we are well into the Season of Greed and Gluttony. You know the season well. It starts with Halloween, where you get all the candy you can. Then, it continues with Thanksgiving, where you eat all the turkey you can. Then, comes Christmas, where you get all the presents you can. It finishes with New Year's, where you drink all the alcohol you can.

We also get to watch the War on Christmas, in which perfectly unreasonable people argue over where to put creches, what to say to each other, and who's more persecuted than they are.

Let us not forget the ancient admonition, "Peace on earth, good will to all. Unless you're different from me. In which case, you can stick it in your ear."

Reparative Therapy

Over at Staff Psychologist, there is a quick post which, citing the Ted Haggard scandal, briefly addresses the issue of reparative therapy. Reparative therapy is an attempt by religious conservatives to try to "cure" homosexuality."

It doesn't work, and it violates the Hippocratic Oath, "First, do no harm." It does a great deal of harm, in that it induces guilt in those who fail in their efforts to embrace heterosexuality. The author, William, Meek, has a great comment about it:

Essentially there is no reparative therapy debate. The American Psychological Association (resolution text) and American Psychiatric Association (resolution text), the two largest organizations representing mental health practitioners, do not recognize it and warn against participating in it. There is also a body of research documenting its ineffectivenss and harmfulness. To me, it represents the worst intersection of cultural judgement, prejudice, and psychology.

'Nuff said.

Love, Marriage, and Enmeshment

Stephanie Coontz, author of Marriage, a History: How Love Conquered Marriage, had an interesting piece in the NY Times today. Last month, the Census Bureau released statistics showing that traditional, married-couple households, are now in the minority. This is her response. She observes that we are overly dependent on our spouses, and this is a new thing in the history of marriage:

Until 100 years ago, most societies agreed that it was dangerously antisocial, even pathologically self-absorbed, to elevate marital affection and nuclear-family ties above commitments to neighbors, extended kin, civic duty and religion.

According to Coontz, the idealization of the nuclear family in the early twentieth century brought us to the current situation:

By the early 20th century, though, the sea change in the culture wrought by the industrial economy had loosened social obligations to neighbors and kin, giving rise to the idea that individuals could meet their deepest needs only through romantic love, culminating in marriage. Under the influence of Freudianism, society began to view intense same-sex ties with suspicion and people were urged to reject the emotional claims of friends and relatives who might compete with a spouse for time and affection.

The insistence that marriage and parenthood could satisfy all an individual's needs reached a peak in the cult of togetherness among middle-class suburban Americans in the 1950s. Women were told that marriage and motherhood offered them complete fulfillment. Men were encouraged to let their wives take care of their social lives.

Coontz is describing what therapists call "enmeshment," and it's terribly destructive to a marriage. Partners in a healthy marriage maintain a balance between engaging their partner and remaining individuals. They maintain a rewarding relationship, but still have a sense of their own individuality. This keeps the relationship stable. In contrast, partners in an enmeshed marriage experience two contradictory impulses.

On the one hand, enmeshed partners get very close to each other. Since they have only a few people in their social universe, a conflict with the partner means conflict throughout the universe. Losing that one person means losing one's entire social universe. That's pretty scary, and the tendency is to paper over conflicts, to give up your own identity to please the partner, and to draw ever closer to him or her.

But then, on the other hand, getting that close to someone represents a loss of individuality. Enmeshed partners begin to resent each other for not being perfect and not being able to provide everything they want. Then, a small problem arises, and starts a fight. The fight rapidly spins out of control as all the resentments against the partner emerge. After the partners are totally exhausted, they withdraw from each other for a while. But then, fears of losing their social universe start to arise again and they paper over their differences and the whole cycle starts again.

Some causes of enmeshment are characterological. People with personality disorders often have poor boundaries. They have trouble maintaining a healthy balance between engaging their partner and maintaining their own separateness. Most of my marital therapy clients don't have that problem. I think they often suffer from a problem at the intersection between family and society. For one thing, as Coontz rightly points out, working couples have little time for independent socialization. What time they do have, they choose to spend with the family. Reasonably enough, they don't want to slight their children or partner by not giving them enough time. I think there is more to it than that.

More and more we raise our children to be dependent on adults. Because of suburban living, our children may not live within walking distance of a park. Because of large schools, their friends may live miles away. So, children must rely on their parents to take them to places to play and to socialize. Children are less likely to go to the park and play a pickup baseball game. Instead, they are members of a baseball league. Organized leagues mean more than just times for the game, the children must also participate in practices. Parents have to drive the children to their activities and we all know the complaints of busy parents who spend their evenings chauffeuring their children around. Frequently, the father drives to one set of activities and the mother to another.

All this takes parents away from each other and further reduces time for independent socializing. They focus exclusively on their family, and are left resenting their spouses for not fulfilling all of what they want. There is a solution to this problem. As Coontz points out:

The solution is not to revive the failed marital experiment of the 1950s, as so many commentators noting the decline in married-couple households seem to want. Nor is it to lower our expectations that we'll find fulfillment and friendship in marriage.

After all, the 1950's and 1960's a time of a rising divorce rate. Maybe Coontz has put her finger on why. She continues:

Paradoxically, we can strengthen our marriages the most by not expecting them to be our sole refuge from the pressures of the modern work force. Instead we need to restructure both work and social life so we can reach out and build ties with others, including people who are single or divorced. That indeed would be a return to marital tradition--not the 1950s model, but the pre-20th-century model that has a much more enduring pedigree.

So, marriages are really products of the community. Healthy marriages are part of a healthy community.

Marijuana Protects against Alzheimer's?

This just popped up on the Psychiatric Times:

As the boomers hit the age where Alzheimer's begins to show itself, it may be that if "they smoked marijuana in the '60s and '70s they don't get the disease, because of that behavior," said Dr. Wenk.


He based the assertion on research he and colleagues have done with rats, not usually known for developing Alzheimer's, nor for that matter, for smoking marijuana.


But as the animals age, Dr. Wenk said, they develop inflammation in parts of the brain analogous to the parts damaged by inflammation in people with Alzheimer's.


Recent research in other fields suggested that cannabinoids -- the active ingredients in marijuana -- can cross the blood-brain barrier, even at low doses, and can reduce inflammation, Dr. Wenk said.


So, in young rats, Dr. Wenk and colleagues created brain inflammation by infusing nanogram quantities of lipopolysaccharide and then treated them with a synthetic cannabinoid called WIN-55212-2.


"We saw an 80% to 90% drop in the inflammation in the brain," he said, "and also the impairment in memory that inflammation produces could be reversed."

There are so many good jokes here, I don't know where to begin....

Distrusting Experts

Judith Warner has had two recent posts (the first here and the second here) in her New York Times blog, Domestic Disturbances, reporting on studues on overscheduling children. In her second post, she states,

When I first read about Mahoney’s study, in Newsweek and then in the Boston Globe, I slipped the stories into a file folder I’ve kept in my office for some time now, labeled “Meaningless Social Science.” Mostly, it is filled with studies on day care. You know the kind: Day Care Causes Aggression, followed two weeks later by Day Care Causes Tooth Decay, followed two weeks later by Day Care Does Nothing Much at all.

This fall brought a wide variety of new entries: Time magazine had a story on whether TV causes autism, while Child had one saying that – contrary to popular belief – TV doesn’t cause attention deficit disorder. The American Educator had an interview with a cognitive scientist debunking everything other scientists have told us is true about left/right and girl/boy brain-based learning styles.

Reading these stories together, and bearing in mind all the contradictory “scientific” studies I have read over time about all kinds of aspects of childhood, motherhood and the interaction of the two, I thought: all these earnest, tightly structured, controlled, peer-reviewed, gleamingly scientific studies don’t have much meaning. Not individually, not reliably, for what they say (or dispute) about TV or A.D.D. or boy/girl cognition or after-school activities.

One commenter to her blog also made a sneering reference to "experts." Since, I guess I'm an expert, I take offense to all this.

It bothers me that the term "expert" has become a synonym for "fool." There has always been an anti-intellectual trend in America, and attacks on expertise (and, by extension, scientists) are a classic part of anti-intellectualism. These attacks seem to become particularly nasty during political eras dominated by demagogues. The McCarthy era of the 1950's was one example. Today is most certainly another. Why? That brings me to my main point.

In one sentence: Reality is not simple. Experts know this; most people don't want to believe it. They want good and bad to be be clear. If you do these things, you're a good parent; if you do this you're a bad parent. We are the good guys; they are the bad guys. My religion is good; your religion is bad. Demagogues play on this desire for simplicity. Unfortunately, if social science has taught us anything, it's that almost everything is open to qualification.

For example, we all agree that divorce is undesirable. Right-wing demagogues often decry the high divorce rate and declare that we have to go back to the good old days and make divorce harder. That way, people will just stay in their marriages, work harder at them, and everything will be fine. A nice, simple solution. But then the scientist says,

"Wait a minute. That nice simple solution won't work. Marriages are more complicated than that." Then the research starts to unfold, yielding complicated, conflicting results, raising more complicated questions:

Yes, children from divorced families are often more depressed and anxious than children from intact households. Hey, but some children do better after divorce when there's a lot of conflict prior to the divorce. But, wait a minute, how do you define conflict? How much is too much conflict? How about the ages of the children at the time of the divorce, how does that affect how well they do? And don't forget about the socioeconomic status of the parents.

All of this challenges the nice, tidy solution of the demagogue. So, it's not surprising that demagogues attack expertise. Today, they have so many outlets on radio, television, and the internet, that their ideas have wide distribution, and it's hard not to be influenced by it. But if you distrust experts, ask yourself this: Who do you want to design a bridge? Who do you want to operate on your heart? Who do you turn to if you're getting depressed?

In the social sciences, experts can inform and make recommendations about social policy and about personal choices. The data is always sloppy and conflicting because research is conducted at the fringes of our knowlege. The perfect answer is never clear. People read stories about the conflicting research in magazines and newspapers and become confused. How does one decide what to do when the experts don't know? This is when they often turn to demagogues and anti-intellectualism. But, those answers are the worst answers.

My answer to this problem is simple: Consider the data. Look in your heart. Then make the best decision you can. That's good enough.

A New Look

A new look to the blog. It's called having too much free time.

Internet Addction or Compulsive Behavior?

Seed Magazine has published an article on Internet addiction . I'm always skeptical about new addictions, whether they be Internet addictions or sexual addictions. To illustrate my skepticism, look at this quote:

Stanford researchers interviewed 2,513 adults in a nationwide household survey. Because Internet addiction has not been clinically defined as a medical condition, study questions were based on established addiction disorders.

Research indicated that nearly 14 percent of the respondents found it difficult to stay away from the Internet for several days and that slightly more than 12 percent often remained online longer than expected.

More than eight percent of the people surveyed said they hid "non-essential" Internet use from family, friends or employers and nearly the same number went online to flee from real-world problems.

Nearly six percent of the respondents felt that their personal relationships suffered as a result of their excessive Internet use.

Substitute "television" for "Internet." What percent of the population, (a) finds it difficult to stay away from TV for several days; (b) watches TV longer than expected; (c) hides non-essential TV use from others; (d) watched TV to flee from real-world problems; and (e) felt their personal relationships suffered from excessive TV-watching?

The last one may be a little iffy, but I've heard a lot of women complain their husbands sit in front of the TV all day, while the husbands rationalize it by saying "I've worked hard all week and I need a little relaxation." I've heard alcoholics rationalize their drinking the same way.

Are we a country of TV "addicts?" I doubt it, although we obviously watch TV too much. I do think that in the social and behavioral sciences, we tend to take concepts and stretch them too far. This is a good example of it.

Never forget that people can do anything compulsively. That includes eating, sex, and (I kid you not) counting. Let's leave "addiction" to substance abuse.

A New/Old Look at Psychoanalysis

The New York Times has an interview with Owen Renik, a psychoanalyst who has just written a book entitled, Practical Psychoanalysis for Therapists and Patients. It controls this wonderful interchange:

Q. You place great emphasis in the book on symptom relief as the central measure of the effectiveness of therapy. Shouldn't that be obvious?

A. Not necessarily. There is a tendency among psychoanalysts to pursue self-awareness as a goal in itself, rather than a means to an end. Originally, the idea was that the self-understanding that arose as a result of psychoanalysis was unique and impressive and valid because it afforded relief from symptoms that were otherwise impossible to treat.

If you don’t require that self-awareness be validated by symptom relief, there are two destructive consequences. The first is scientific. You have no independent variable to track; you set up a circular situation in which it’s the analyst’s theory that determines what is found in analysis. Many critics of psychoanalysis have recognized this.

But an equally important consequence is that you relieve the analyst of any accountability. The process can go on forever, and there are all kinds of temptations to extend it, including the therapist’s vanity, his inability to admit failure, his narcissism — and nobody likes lost income. The therapy then becomes an esoteric practice of proselytizing, rather than a discipline, and the proof of that is everywhere in the world, where fewer and fewer people go to analysis at all. If the therapy worked, people would be going.

This issue actually goes back to 1952 when H. J. Eysenck had argued that psychotherapy was ineffective (a 1957 paper is available here). At the time, psychoanalysis was the dominant form of psychotherapy. Although deficiencies with his research have been well documented, his paper touched off the field of psychotherapy research, and such studies continue to this day. Generally, it has been concluded that certain forms of problem-oriented psychotherapy (e.g., cognitive therapy, behavior therapy, and interpersonal therapy) are effective for treatment of anxiety, depression, and other specific psychological problems. Psychoanalysis, and other psychodynamic therapies have not fared so well, although I have seen a few positive studies in the past.

The issue is not just whether or not psychotherapy "works;" it's also whether or not this particular client is benefiting from a particular therapy, from this particular therapist. This is what we call accountability, and psychologists have not taken it seriously enough. I'm particularly impressed with Renik's eloquent comments about the dangers of not addressing symptom relief in therapy, i.e., not being accountable.

Today, it is becoming more common for therapists to begin sessions with a fairly straightforward questioning of a client about his or her level of symptoms. A quick minute of asking about mood, sleep, appetite, frustration tolerance, and so forth can provide adequate data for accountability. It also helps discourage the conduct of endless, directionless therapy, whose sole hallmark is to keep the client coming back for another fully paid session.

The Lancaster School Shootings

Like most of my colleagues and neighbors, I've been following the Lancaster school shootings with great interest. I've been wanting to blog about it, but I'm hesitant to jump in with both feet.

So far, I don't know what to make of it. When the news first hit, a friend of mine and I both assumed that the motivation for the shooting was that the shooter had been sexually molested, probably at a school. Instead, the information coming out makes no sense.

The shooter left a message that he had molested two children about 20 years ago, and the memory has always been very exciting and vivid to him. The women, who at the time were 4 and 5 years old, have no memory of this. That's not surprising. At that age, they might not. However, it's very unlikely that he didn't offend for another 20 years, and it's even more unlikely that this would motivate this kind of behavior. Instead, he would be expected to reproduce the same events a second time. Not this kind of bizarre, carefully planned act.

A second explanation left in his messages was that he was angry at God for the death of his daughter soon after birth. Again, his current behavior has no link with that past trauma. I can see suicide, perhaps even a dramatic suicide, but not one connected with assault on children, most of whom he apparently knew.

No, I'm afraid we're still missing some pieces of the puzzle. I'll keep an eye out for more information.

More Complaining about Evidence-Based Treatment

The most recent edition of the National Psychologist contains two articles concerning evidence-based treatment. Unfortunately, the online edition hasn't been updated yet and the articles are only out in hard copy.

For those of you who are not of the cognoscenti, evidence-based treatment is simply treatment with a clear research base. The research establishes that certain procedures are helpful for certain types of problems. My previous post describes an evidence-based treatment for OCD.

The first article, by Thomas Habib, opens with a bizarre story. Apparently a managed care network, Managed Health Network, wants to establish a category of, what Habib calls, an "elite clinician." I'm not sure if it's Habib's words or theirs'; I couldn't find it on their web site. Essentially, this elite clinician would be someone who has been trained in and practices evidence-based treatment. I assume that these elite clinicians would be given priority in referrals.

Habib is worried about the perceived deadly combination of managed care and evidence-based treatment. He states,

No one is against evidenced based practices. As mentioned above, how this goal was pursued and the disregard of how this might strait jacket psychology and be misused by mangled care is the problem.

"Mangled care" is an obvious shot at managed care. Certainly somewhat deserved, but then, our hands aren't entirely clean, either. There have been far too many clinicians who weren't good at getting change, but were very good at keeping clients in therapy for extended periods of time.

Managed care credentialing for clinicians doing evidence-based treatment is silly. From experience, I know this will fail, because it won't save MHN any money. Back in the 1980's, when managed care blew into Pennsylvania, I spent an incredible amount of time on the phone with "care managers," who would authorize treatment for my clients. Once I learned what they wanted to hear, it was no problem to get sessions authorized. I got to know a lot of care managers by name and we'd chat about our families before getting down to business. But, eventually, telephone authorizations became too expensive, and most of my telephone friends had to get other jobs. Now, my secretary fills out a page, I add the diagnosis, and sign it. Bingo! Another 10 sessions.

So, let me assure you, Dr. Habib. This will end with a whimper, and you'll be left with a mild bit of bureaucracy. Nothing to get excited about. Managed care isn't going to hurt you with evidence-based treatment requirements because it's too expensive to do so.

But, is evidence-based treatment a "strait jacket?" Absolutely not, and the second article illustrates my point clearly. Surprisingly the author, Frank Dattilio, also thinks he's attacking evidence-based treatment. He should really know better, as he has extensive training and publication in cognitive-behavior therapy. In his article, he tells the story of Corey, a young psychiatrist completing his fellowship. Corey brought him a tape of a therapy session, of which he was very proud. Dattilio viewed the tape and said,

Much to my dismay, the same things kept cropping up repeatedly during the course of the session--a dry, robotic type of interaction that almost appeared as though it was scripted.

At the end, Corey said to me, "So what do you think?" I was speechless. Before I had a chance to say anything, he interrupted me by saying, "I think it's classic cognitive-behavior therapy. I don't believe I left one thing out."

"Well, there is one thing that is missing," I replied. Corey looked at me perplexed, "What did I forget?" "You!" I exclaimed, "You, the therapist is missing."

It's a wonderful story, and a great cautionary tale to young therapists, who, unsure of themselves, want to retreat into "techniques." Since the 1950's, we've known the quality of the therapeutic relationship has a strong effect on therapeutic outcomes. Wampold (2001) has a good review of the data. Maintaining a good relationship with the client, being empathic and supportive, is part of any evidence-based treatment. Just look at Beck, Rush, Shaw, and Emery (1979).

The sad thing is that we continue to argue about evidence-based treatment even though we consider psychology to be a science. If psychology is a science, we believe the data. If psychology is a science, we opt first for treatments that the data shows are worthwhile. No one expects us to give up our clinical judgment and our empathy in the process. Being empathic and supportive is just another evidence-based therapy.

All psychotherapies are like seeds. They cannot grow into a beautiful flower without the fertile soil that the humanity of a good therapist provides. Clinicians do not need to fear evidence-based therapies.

References

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.

Dattilio, F. M. (2006). Evidence based treatment may be too confining. National Psychologist, 15(5), 23.

Habib, T. A. (2006). A profession in search of legitimacy. National Psychologist, 15(5), 14.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Earlbaum Associates.

Obsessive-Compulsive Disorder

A good summary of psychotherapy for OCD, written by Bradley Riemann, appeared in the Psychiatric Times last month. The article opens with this observation:

Obsessive-compulsive disorder (OCD) is a common and debilitating condition. In many cases, it can come to dominate a person's behavior and cognitive processes, creating great anxiety. It typically affects all aspects of an individual's life, including school performance, occupational responsibilities, and family and social interactions.

Although the television show "Monk" strives for laughs about it, there is no humor OCD. It can be absolutely debilitating. The worst thing about it is that the client knows his or her behavior is irrational, but can't stop doing it.

The heart of treatment for OCD is exposure and ritual prevention. There is typically a feared situation, which is followed by some form of ritual to reduce the fear. For example, a client may go to the bathroom and then compulsively wash his hands for the next 20 minutes. Treatment is straightforward.

First, the client begins with a mildly anxiety-provoking response. For example, he might go into a public bathroom and touch the sink. This exposure creates anxiety. Normally, the client would reduce the anxiety by hand washing. Instead, the handwashing response is prevented. The client waits for the anxiety to drop, which it always does. The procedure is repeated until there is no more anxiety. Then, the client moves on to a more anxiety-producing stimulus, such as a toilet seat.

This procedure has two effects. First, the anxiety is extinguished by a process called habituation. Recall learning to drive. At first, you were quite anxious. As you drove repeatedly, you became less anxious. Through repeated exposure, you habituated to driving.

Second, the client learns an important lesson. Anxiety always goes away. If you tolerate anxiety for a period of time, it always goes away. This gives the client tools for dealing with other compulsive behaviors.

Psychotherapy for OCD is critical. Riemann cites research indicating that antidepressant medications can reduce symptoms of OCD by about 1/3, so medication alone won't provide full relief. Unfortunately, our office procedures are not always sufficient for good treatment. For exposure and response prevention to be truly effective, a person with OCD needs intensive treatment, usually outside the office. Treatment centers are being established in order to meet this need.

Update

It worked!!!
(I think...)

Here we go....

I just spent yesterday and this morning removing a Trojan horse from my wife's computer. It was easy enough to identify the infected file. I just couldn't delete it, the sneaky devil. I finally figured out that starting the computer in Safe mode would let me delete it. It worked.

Anyway, always a glutton for punishment, I'm now going to revise my blog to take advantage of the new features in Blogger Beta. I figure there are three possible outcomes: (a) It can transfer; (b) my computer can wind up dented in the street; or (c) I can page furiously through Albert Ellis's book, Anger: How to live with it and without it.

Since the first outcome is the least likely, I'm hoping for the third outcome....

Canton School Board Abandons Abstinence Only Sex Education

This story is certainly not surprising:

An Ohio school board is expanding sex education following the revelation that 13 percent of one high school's female students were pregnant last year.

There were 490 female students at Timken High School in 2005, and 65 were pregnant, WEWS-TV in Cleveland reported.

We live in a very sexual society, but under the current conservative philosophy, we are not allowed to educate our children about sex. As a result, we have the worst of both worlds. All of the advertising and movies out there encourage children to have sex, but children have little knowledge of appropriate sexual behavior.

Telling children, "Just don't do it," isn't good enough, as Timken High School found out. Children need to be taught what responsible sexual behavior is. Once they understand that, it's easier to show them that having sex during childhood is always irresponsible.

That first sexual experience is always done for the wrong reasons: To find out what all the shouting is about; to prove you're a "Man" or a "Woman"; to keep your lover happy; or because you're supposed to have sex on your wedding night. So, the first sexual experience should come at a time when you have the maturity to deal with all the emotional and physical fallout from bad sex.

It's good to see that the adults running Timken High we willing to look at the data, cast ideology aside, and do what's good for their students.

A Slow Summer

This is a slow summer, and I've had little to blog about. That's not to say I haven't been busy. I've been running up my contact hours like crazy.

Normally, August is a slow month for clinicians. My take on the pattern is that people are taking vacations, and with good weather, people are out, doing enjoyable things, and lifting their moods. During the winter, in contrast, people stay inside, gradually going stir crazy. By February and March, they're calling for help.

This August, however, has been anything but slow. I wonder if it's because it's been so hot, people are staying inside, in the air conditioning, going stir crazy. I keep praying for a cancellation or no-show so I can catch up on my paperwork.

So what makes this summer slow? Mostly, it's the absence of news. The research presses have slowed down for the summer. They'll gear back up for the new academic year.

There have been only two interesting stories this month. A new research study on post-traumatic stress disorder (PTSD) challenges a previous estimate of the risk of PTSD. A previous study estimated that 30.9% of Viet Nam veterans experienced symptoms of PTSD. The new study, which is apparently much more rigorous, concluded that the number should be 18.7%.

I've heard no complaints about the methodology in the study, and from what I've seen, it does look pretty solid. Still, dropping the risk factors from just under 1 in 3 to just under 1 in 5 is nothing to write home about. War is still a pretty scarring business.

Despite this data, veterans returning from Iraq seem to be reporting symptoms at a 1 in 3 rate. Apparently, it's because a greater percentage of soldiers are serving in combat roles, compared to the Viet Nam war. Now, support jobs going to soldiers are going instead to civilian contractors. And, by the way, we don't have data on the contractor's risk of PTSD.

I really wish we would never again have to do research on the risks of PTSD in combat.

Another story, which just popped up today in the New York Times concerns pedophilia. Using conversations from chat rooms, the Times was able to draw a very convincing portrait of the rationalizations and defenses pedophiles use to explain away their own behavior.

Psychological defenses are amazing things. Drunks create chaos in the family, and everybody looks the other way, insisting their family is perfectly normal. The old substance abuse counseling line that "Denial is not just a river in Egypt," is equally applicable to pedophiles themselves.

Spirituality and Religion: A Personal Approach

A few weeks ago Mark Isaac, on The Panda's Thumb wrote a piece entitled, The Larger Issue of Bad Religion. It created quite a stir. I was tempted to comment, but I needed time to think about it. By the time I got my thoughts together, the comments had gone south. They devolved into insult, and the last comment on the blog just repeated the phrase, “religion sucks!” more times than I want to count.

It occurred to me that identifying “religion” as “good” or “bad” is useless, because “religion” is a very broad concept. There is no single set of “religious” practices or beliefs. If you don't believe me, just compare Catholicism to Pentecostalism to Orthodox Judaism to Reform Judaism to Unitarianism. It's all religion, but it sure ain't the same. To make decisions about what is good and bad about religion, we need to be more specific.

If “religion” is a brand (e. g., Christianity, Judaism, Protestantism, Islam, Buddhism), then “spirituality” refers to their component beliefs and practices. We can evaluate each individual component itself, and can then decide for ourselves what kinds of spiritual practices work for each of us individually. This is not a new thought for me. I'm an individualist, and refuse to let others make my spiritual decisions for me. But, it was a new and direct approach to doing it. I got really excited and started listing spiritual practices in bipolar form. Then, two problems jumped out at me.

First, on what scale do I evaluate these components: “Good vs. bad,” “healthy vs. unhealthy,” “toxic vs. nourishing,” or something else? Second, as I wrote out my list, I suddenly realized that I wasn't evaluating religion or spirituality. I was describing my own beliefs.

I've spent a lot of time thinking about my beliefs, and have been struggling with an ethical will. So, if I'm describing my beliefs, it's narcissistic for me to say, “These beliefs are good, and these beliefs are bad.” That was the solution to both problems.

Below, I've generated a list of spiritual beliefs and practices that I either embrace or reject. You may agree or disagree with me; I don't care. I do think there are some truly toxic beliefs; I've discussed them before. But, this list is more than just a discussion of toxic spirituality.

I embrace spirituality: That helps me find meaning in life.

I reject spirituality: That imposes meaning on me.

I embrace spirituality: That encourages me to find faith through reason.

I reject spirituality: That encourages me to "just believe."

I embrace spirituality: That inspires me to be more ethical.

I reject spirituality: That uses fear and shame to motivate me.

I embrace spirituality: That teaches respect for others.

I reject spirituality: That teaches God likes you better because you're one of us.

I embrace spirituality: Where nonmembers are taught about one's beliefs.

I reject spirituality: Where nonmembers are told, “Our beliefs are better than yours.”

I embrace spirituality: That encourages involvement with the larger community.

I reject spirituality: That encourages withdrawal from the larger community.

I embrace spirituality: That sees pleasure as a legitimate part of life.

I reject spirituality: That encourages self-denial and elevates suffering.

I embrace spirituality: That comforts people cope suffering from misfortune.

I reject spirituality: That blames people for their misfortunes.

I embrace spirituality: That accepts human fallibility.

I reject spirituality: That demands perfection from humanity.

I embrace spirituality: That encourages people to make the world a better place.

I reject spirituality: That encourages people to tolerate things as they are.

I embrace spirituality: That uses ritual to reinforce beliefs or connect with the past.

I reject spirituality: That uses ritual to please God.

This list is far from exhaustive. I'll probably spend the rest of my life populating and revising it. Generate your own list. It's a great experience.

New Psychology Advocacy Group is Formed

The National Psychologist reports that a new advocacy group, the National Alliance of Professional Psychology Providers, has just been formed. Their web site states,

The National Alliance of Professional Psychology Providers (NAPPP) is a new, nonprofit organization for professional psychologists to advance and secure the practice of psychology. The purpose of NAPPP is twofold. First, we will function as an advocacy organization to assertively protect and advance scope of practice issues through lobbying, legislative and litigation strategies. Second, we want to help educate and inform practitioners about the business of practicing psychology so that this much ignored aspect of the profession can grow and develop.

It sounds good. Although NAPPP doesn't describe itself as a replacement for the American Psychological Association (APA), it certainly could fill a gaping hole.

I dropped out of the APA for two reasons. First, because the APA seemed to be disinterested in protecting practitioners from the erosions of managed care. When managed care came in, they...well...managed care. Managed care wanted to see that their dollars were being well spent. They were at times intrusive, and always were a pain in the ass, and APA took a stand against managing care. Unfortunately, APA missed the bigger problem until it was too late.

The real problem was that managed care eroded our fees. As a result, caseloads skyrocketed. Twenty years ago, 20 clients a week was considered a full time load. It paid for the clinician's salary and the office overhead. Today, it takes 30 clients a week. The APA has done nothing about that. Managed care oversight is essentially gone, at least in Pennsylvania, because it was too expensive. But, the fees are still lousy. So, a word of advice: Never see a psychologist late on a Friday afternoon.

The second reason I resigned was the inability of APA to stand by it's belief that psychotherapy could be a practice based on scientific principles. Some forms of psychotherapy, such as cognitive therapy and interpersonal therapy, have some pretty good evidence for their effectiveness. Yet, when questionable therapies, such as rebirthing therapy, emerged, the APA has been silent. Eventually, rebirthing therapy killed a child. Organized psychology should be taking strong stands against pseudoscience, and it's not.

So, I hope that NAPPP does well. At $240 annually for membership, it's a little pricey, but it could be worth it. I'm considering joining.

A few days ago, the US Supreme Court ruled on another wrinkle in the insanity defense. An Arizona man, clearly schizophrenic, argued that his illness prevented him from forming the requisite intent to commit a crime. According to the New York Times:

The case was brought by an Arizona man who was a teenager suffering from paranoid schizophrenia when he shot and killed a police officer. He was convicted of violating a law that makes it a crime to kill a police officer intentionally, and he argued that the delusions caused by his illness had prevented him from forming that specific intent.

The key to the case involved the word, "intent." The defendant argued that because he was schizophrenic, he couldn't have formed any intent. The Supreme Court, keeping it's ideological purity intact, essentially dodged the issue with a narrow ruling. Writing for the court, Justice David Souter said that the states were so varied in their approaches to insanity, that there is no single, unambiguous standard for legal insanity. It's a sad state of affairs that this is true.

The court system is teetering between three models of criminal behavior: Moral, psychosocial, and medical. The moral model attributes criminal behavior to immorality. If you punish the immoral behavior, it will stop. The psychosocial model attributes criminal behavior to a complex interaction among family, community and economic causes. The medical model holds that criminal behavior is the result of genetic and biological causes.

All three models have their elements of truth, but the moral model holds sway, to the detriment of the other two. Criminal behavior does need to be punished, but, we should also attend to the social and economic framework in which criminal behavior occurs. Social inequity is the fertilizer in which criminal behavior grows.

We are becoming convinced that schizophrenia is primarily a medical problem. Why are we holding schizophrenics accountable for their behavior in the same ways that "normal" people are? It's a sad thing that we no longer see social services as a force for good. Even though crime rates drop during good economic times, even though education is a proven route to rehabilitation, we are still committed to the moral model to the exclusion of the others. It's a shame that compassion is passe.

Advice for Other Psychologists

If you're like me, you dread telling people what you do for a living. You tell them you're a psychologist, and somebody always says, "We better watch out what we're saying!" A real original comment. I finally came up with the perfect response:

"Don't worry. Your secrets are safe with me."

If I'm feeling particularly sadistic, I can add, "You know that sexual issue you have? Don't worry, I won't say a word."

Who was Freud?

Over at Frontal Cortex on the newly expanded ScienceBlogs, Jonah Lehrer compares Malcolm Gladwell (author of Blink, in which he discusses rapid, unconscious, "snap" decision-making) to Sigmund Freud:

Sigmund Freud was also a master prose stylist, wasn't particularly interested in the neurological foundations of his theories, and loved theorizing about the all powerful unconscious. (Like Gladwell, he also loomed large in mass culture and had a talent for giving his books pithy names, although I'm pretty sure Freud never made the rounds of the corporate lecture circuit...) Blink could have been a great book. It could have really explored the modern science of unconscious thinking.

I haven't read Blink yet, so this post isn't about the book. Instead, I am concerned about the trivialize of Freud. Freud was a brilliant man. (No, he wasn't obsessed with sex.) Much of psychoanalysis has been put aside, but it was Freud who recognized that there can be pathology in thought. He recognized that there is value in introspection. He created the idea of the therapeutic relationship, and these ideas have woven their way into the fabric of our lives.

Freud was a visionary. His power came, not from being a literary stylist (he didn't even write in English), but because he presented a compelling new vision of humanity. Today, that vision is dated. Popular conceptions of psychoanalysis inevitably simplify it, and those simplifications seem very trite.

Nevertheless, Freud's vision of the human psyche changed the way we think about ourselves so fundamentally, we take it for granted. For some people, no argument with our spouse is complete unless we have introspected about our motives. Did I really tell here what I was angry about? Is there another issue I'm not facing? The idea that our motives can be hidden from ourselves came from Freud.

As parents, we worry how our parenting will affect our children when they grow up. That came from Freud.

As I've said before, I'm not a psychoanalyst. But I have to respect Freud's vision, his creation of a whole new way to help people, and his contribution to our current culture.

Psychological Effects of Day Care

The New York Times has a summary of an extensive study on daycare, conducted in Quebec. In 1997, Quebec began subsidizing daycare for all 4 year olds, regardless of income. By 2000, the program was expanded to include all children not in kindergarten. The program was very popular, and resulted in significant economic expansion in Quebec. Three economists, Michael Baker, Kevin Milligan, and Jonathan Gruber collected data on the well-being of the children going through daycare.

They compared those results with children in the rest of Canada during that same period. Unfortunately, they found that the children in daycare did not fare so well. The Times reports:

Young children in Quebec are more anxious and aggressive than they were a decade ago, even though children elsewhere in Canada did not show big changes. Quebec children also learn to use a toilet, climb stairs and count to three at later ages, on average, than they once did. The effects weren't so great for parents, either. More of them reported being depressed, and they were less satisfied with their marriages — which also didn't happen in other provinces.

I can hear the pontificating now. Mothers should stop trying to work and just stay home with the children. Enough of this liberal working mother stuff and be good, pro-family conservatives!

Ecch.

David Leonhardt, the author of the Times article, makes the following comment:

The big lesson from Quebec is that parents really do need more support, but they need the kind of support that allows them to choose what is best for their family. Mothers and fathers should get paid time off after a baby is born, and the money should come from a government insurance program, as it does in Canada, England and other countries. Companies need to be given incentives to create more part-time jobs that don't derail careers — and then find some up-and-coming men who want those jobs. High-quality preschool programs should be available for every low-income child and perhaps universally.

Wouldn't that really be pro-family?

Intermittent Explosive Disorder: The New Rage?

Sorry, I couldn't resist the title.

Apparently, intermittent explosive disorder (IED) has hit the popular press. I've seen about 3 or 4 different references to it in the last week. The stories have been confusing it with road rage, but it's not. IED has been a diagnosis for years.

The whole thing follows a predictable arc:

1. An obscure diagnosis sits in the current Diagnostic and Statistical Manual.
2. Someone finds a way to use it to sell drugs. psychotherapy, or self-help books.
3. It catches the attention of the press.
3. It gets initials (e.g., IED) and becomes overdiagnosed and overtreated.
4. Warnings are issued about overdiagnosis.
5. Clinicians who benefit from the diagnosis argue that in the past it was underdiagnosed.
6. It continues to be overdiagnosed.
7. In some cases, associations get formed, and the diagnosis starts getting used as an excuse for underachievement or misbehavior.

We saw this with attention deficit disorder. Now Ritalin is rampant, and people with ADD get longer to take tests. A few years ago, oppositional defiant disorder followed the same arc, as did autism. Now, intermittent explosive disorder is hitting the same arc.

For the record, clinicians have been treating anger for many years. I recall diagnosing intermittent explosive disorder a few years ago, and having the insurance company kick the claim back saying they don't cover it. When this happens, clinicians always fall back on the same strategy. You avoid diagnoses that you don't get paid for.

That's not quite as dishonest as it sounds. A quick perusal of the Fourth Edition of the Diagnostic and Statistical Manual (DSM-IV) will show that multiple disorders manifest the same behavioral symptoms. For example, irritability and rage are the prime symptoms of intermittent explosive disorder, but, they are also associated with unipolar depression, bipolar disorder, attention deficit disorder, conduct disorder, and various personality disorders.

So, in the past, to assure payment, we treated anger as a symptom of another diagnosis. IED wasn't very common because no one was diagnosing it. I could be wrong here, but it's my recollection that when the Columbine School shootings occurred, more attention was brought to the problems associated with anger. We started to hear about "anger management," and I suspect this led to more diagnosis of intermittent explosive disorder.

So, two takeaways from this. First, diagnosis in mental health is not the same as in physical health. Despite all the huffing and puffing about biochemical imbalance, we have no clear understanding of the underlying mechanisms of depression or other mental illnesses. This means that ultimately "diagnosis" involves just summarizing what particular symptoms are being treated. It says nothing about etiology.

Second, diagnoses are influenced by social and economic factors. After Columbine, we stopped thinking that anger was just a matter of rudeness and immaturity. Now we think it's something serious that should be addressed, and our patterns of diagnosis have changed as a result. Let us not forget, however, that from spousal abuse to school shootings to office shootings to road rage, anger is a real problem.

I don't want to see it trivialized, either. I'm sure we'll soon hear, "I shouldn't be found guilty for running that man off the road because I have intermittent explosive disorder." That doesn't fly. IED is a serious problem and a treatable one, but it's not an excuse.

Early Infant-Mother Attachment

The latest issue of Current Directions in Psychological Science contains an interesting article on early infant-mother attachment, by Myron Hofer. His work is based on research with rats, but nevertheless, there is much interesting data that is relevant to humans.

The term, attachment, as Hofer uses it, refers to “the processes that maintain and regulate sustained social relationships” (p. 84). Attachment between mother and infant is the first bond that occurs. Much clinical and social experience over the last 50 years has shown that inhibiting this process has long and severe consequences for the infant. The current thinking is that both reactive attachment disorder and antisocial personality disorder stem from impaired attachments during infancy and childhood. There are also suggestions that borderline personality disorder is also related to disrupted attachment.

Hofer addresses three issues. First, he presents data suggesting the attachment bond is created through the interaction of mother and infant through a complex pairing of stimuli. Apparently, there is an early period, immediately after birth, when the infant rapidly learns to associate smells, sounds, taste, and touch with the mother. It happens quite rapidly, enabling the infant to discriminate the mother from other parents and probably from other objects in the infant's environment.

Interestingly, Hofer mentions some data that indicates that aversive stimulation may intensify the bonding. He links this finding with the intense bond between a child and an abusive parent, and why this occurs needs to be clarified. Rapid bonding between the infant and the mother makes good sense from an evolutionary point of view. The mother provides all of the infants needs for survival, so the sooner the infant can recognize the mother the better. But the reason for increased attachment in the face of pain makes no sense to me.

The second issue involves the question of why maternal separation is stressful. Hofer says that basic biological processes are initially regulated by the mother in subtle ways. In describing an experiment with rats, he commented, “We concluded from these surprising results that warmth provided by the mother normally maintained the pup's activity level and that her milk maintained her pup's heart rate. Maternal separation withdrew these regulatory influences that were hidden within the ordinary mother–infant interactions, resulting in slowed behavior and low heart rate.” (p. 86).

The final issue Hofer addresses is why disruption of the early maternal-infant relationship can have lasting effects. Hofer argues, “when all maternal regulators are withdrawn early, a number of physiological and behavioral systems are altered in their developmental paths and in their relation to each other, creating a complex, changing pattern of vulnerability over the life span.” (p. 86). Interestingly, not all those changes are negative, which is consistent with what humans will tell you.

People who have gone through arduous childhood experiences often comment that they take away some positives from it. For example, some of my clients have said that because of the abuse they suffered as child, they have learned to manage stress better than their friends. They do not minimize the experience or deny how bad it was. They simply recognize that they did manage to take something positive from it.

Finally, it's always a pleasure to read a basic science article that has implications for practice. There's an awful lot of stuff out there that will never be of any real use to anyone beyond a line on a vita.

Hofer, Myron A. (2006). Psychobiological Roots of Early Attachment. Current Directions in Psychological Science 15 (2), 84-88. doi: 10.1111/j.0963-7214.2006.00412.x

Available on-line $

Toxic Spirituality and Naive Spirituality

Here is central Pennsylvania, things are just a little conservative. It's the only part of the state, for example, where Senator Rick Santorum is still leading in the polls. (Don't get your hopes up. Santorum will probably lose, but Bob Casey is barely a Democrat.)

In a conservative area like this, fundamentalist spirituality is pervasive, and frequently, it can be toxic. Toxic spirituality encourages people to think of themselves in black and white terms. I am either good or bad. Usually, since we can't be perfect, we're bad. Bad things that happen to us are our fault. If we had been better people, nothing bad would happen to us.

I encounter it frequently, because toxic spirituality encourages guilt, and guilt is a path to depression. For my clients, it's not a hard thing to deal with. You start off by pointing out that people do good things and bad things. Then you ask, if you did 1,000 good things and 1 bad thing, would you be a good person or a bad person. Most of the time, people respond that they'd be a good person. Then I ask if they did 1,000 good things and 2 bad things, would they be a good person or a bad person?

By this time, they start to get the point. But then, my clients aren't the hard core fundamentalists, so they're not as locked into that kind of thinking. More of my clients manifest a more subtle problem, which I call naive spirituality.

People with naive spirituality embrace beliefs that are brittle and unrealistic. Frequently, their beliefs revolve around the idea that God intervenes in this world to protect them or to make things work out for them.

Then, of course, something awful happens and they feel abandoned by God. This leads them right into thinking, "I must be a terrible person, because God is punishing me." So, naive spirituality is the precursor of toxic spirituality.

Yet, it's often difficult to break into naive spirituality. People don't see the need to change it until it becomes toxic. After all, it's very comforting to believe that God will protect us. It's just not true. Check the paper. Check the history books. How many soldiers would die in wars if God was protecting us?

Evil happens because the world isn't perfect. A healthy spirituality recognizes that bad things will happen to innocent people. A healthy spirituality will also inspire people to correct the things that have hurt people.

Often, when I encounter naive spirituality, I encourage people to read two of Harold Kushner's books, When Bad Things Happen to Good People, and How Good Do We Have to Be? It's hard to get people to face these issues directly, so I often suggest that they read Kushner just to get a different perspective. Often, that's a good start.

The critical thing is this: You cannot challenge someone's spirituality without supplying an alternative. Similarly, when you provide the alternative, don't be surprised if the person walks away with something different from what you provide. Just work to make sure that what ideas they get help them develop a healthier spirituality.

Suicide by antidepressants? A clarification

In my previous post, I was talking about the role of SSRI's in stimulating manic episodes. I made an error where I commented,

It's possible, then, that SSRI's may cause a manic or hypomanic episode in bipolar clients who have been misdiagnosed with recurrent depression.

While that is true, I neglected to get where I was going. Some people do not have pure manic or hypomanic episodes. Instead, they have mixed episodes, where symptoms of mania mix with symptoms of depression. A person who is depressed, suicidal, agitated, and impulsive can be very high risk of suicide.

So, I was addressing concerns about SSRI's causing manias. I should have been addressing concerns about SSRI's precipitating a mixed episode.

By the way, one of the best books I've read about bipolar disorder is An Unquiet Mind, by Kay Redfield Jamison.

Suicide by Antidepressant?

According to the New York Times ,

After analyzing data from clinical trials, GlaxoSmithKline has sent letters to doctors warning that its antidepressant drug Paxil appears to increase the risk of suicide attempts in some young adults.

We've known for a while that Selective Serotonin Reuptake Inhibitors (SSRI's) sometimes cause agitation and suicidal ideation in depressed adolescents, but this is the first time that SSRI's have been linked to the same behavior in young adults. It's important to note, however, that the study reports increased risk of suicidal ideation and suicide gestures. It did not identify an increased risk of completed suicide.

I can recall a few cases like this. Both the psychiatrists I worked with and myself were mystified. It was terrible to watch someone get good care and deteriorate so quickly. One client wound up in a state psychiatric hospital for about three months and was still quite agitated and bizarre after discharge. He was still on the same SSRI he was admitted on.

Nobody is too sure why these antidepressants, SSRI's such as Paxil, do this. The original thinking identified the psychology of depression. There are two different aspects to depression: the cognitive and the behavioral. Almost all depressed clients manifest cognitive changes, consisting of self criticism and pessimism. Behaviorally, many clients also manifest vegetative symptoms. They have little energy, they have difficulty getting out of bed, and they can't concentrate or organize their behavior.

These vegetative symptoms are actually protective. A depressed, suicidal, individual, who is also vegetative can't organize his or her behavior well enough to commit suicide. But with treatment, the vegetative symptoms may lift before the cognitive symptoms, leaving the client more capable of planning and carrying out a suicide. Every clinician, treating with drugs or psychotherapy, worries about this.

This is what we thought this was happening when clients on SSRI's became suicidal. Unfortunately, the data didn't support that. The agitation lasted too long and risk of suicide lasted even after the cognitive symptoms had improved.

I suspect that we are seeing something else. We've also known that SSRI's increase risk of mania in bipolar clients. Bipolar disorder , previously called manic-depression, consists of mood swings, from depressed (often with vegetative symptoms) to manic. The mania is marked by agitation, impulsiveness, irritability, grandiosity, and insomnia. Some forms of bipolar disorder manifest a milder form of mania, called hypomania. Hypomania, looks a lot like agitation with impulsivity. So there are three hypotheses:

First, some of these depressed clients, who react badly to SSRI's, may actually be bipolar. Bipolar disorder usually emerges in adolescence or young adulthood. It's not unusual for there to be a period where the client is diagnosed with recurrent depression. It's not until an unmistakable manic episode breaks through that we diagnose bipolar disorder. It's possible, then, that SSRI's may cause a manic or hypomanic episode in bipolar clients who who have been misdiagnosed with recurrent depression.

Second, most depression fluctuates. That is, a person who is clinically depressed may also have periods where he or she feels pretty good, or at least, not terrible. Then, there are other times when he or she feels suicidal and vegetative. I wonder if there is, at a biochemical level, some similarity between bipolar disorder and some recurrent depressions. To what extent does this similarity cause similar responses to SSRI's?

Finally, the adolescent brain still is developing the structures necessary for impulse control. I wonder, here, too, if the SSRI's differentially affect the adolescent brain. It is possible that these structures have not fully developed in the brain of the young adult, too.

In any case, until we can improve our understanding of this problem, we need to increase our monitoring of depressed patients. Physicians should never prescribe SSRI's or any other antidepressant to an unknown patient and send them away for 3 months.

Obviously, my preference would be referral for psychotherapy, but even that strategy is prone to problems. Most therapists I know today are overloaded. I often can't see someone for two or three weeks after the initial appointment. I have to schedule several appointments to keep seeing a client on a regular basis. This leaves the client unmonitored for a few weeks during the most critical period of starting medication. Fortunately, my employer has a crisis team, who, on my instructions, can call a client in crisis on a specified schedule to check on them. This study should encourage changes in practice for all practitioners.

Thanks

I just noticed a link to my blog from Science and Politics .

Thanks, Bora! I promise to post more on science in the future. The other stuff is much easier, and I've been overwhelmed with work lately.

Ethics and Clinical Psychology

Ethical issues are always a concern for most psychologists. As the profession has grown, the ethics code has grown from a brief statement to a whole field of study. Professional ethics create tremendous anxiety for clinicians. Let me scratch the surface by citing an article posted by Ken Pope on his web site.

Pope reports the results of a recent survey of American Psychological Association members on ethical dilemmas. The abstract notes:

A random sample of 1,319 members of the American Psychological Association (APA) were asked to describe incidents that they found ethically challenging or troubling. Responses from 679 psychologists described 703 incidents in 23 categories.

As always, the response rate (just under 50%) raises questions about how representative the results are for American clinical psychologists. But the data does show some interesting trends. First, of the 679 responses, 134 reported experiencing no direct experience of ethical dilemmas. Of the remaining responses, 49% fell into three categories: (a) confidentiality, (b) blurred, dual or conflictual relationships, or (c) payment sources, plans, settings, and methods. Let me give you an idea of what psychologists deal with on a regular basis by just touching on pieces of these three areas.

a. Confidentiality. A clinician cannot reveal any information about a client without the client's consent. There are only three exceptions. First, a judge may order a clinician to reveal information over the client's objects. This rarely happens. It may happen when the client is accused of criminal activity and might have disclosed it to the clinician.

Second, the clinician must reveal information to protect a client who is likely to harm the client or others. This happens more frequently. A depressed client calls a clinician and indicates he is suicidal. If the client refuses to go to the hospital voluntarily, the clinician can initiate involuntary commitment procedures.

Finally, clinicians are required to reveal ongoing or recent information to the authorities concerning sexual or physical abuse of minors (and in some cases, the elderly). There is always real concern about balancing the interests of an abusing client against protection of an abused child. While in some cases it's a no-brainer to report, there are other cases where the abuse is suspected or probable, and the clinician must make a judgment call as to whether or not to report. Remember, when you report your client to the authorities, you may be ending your relationship with the client. If you made the wrong call, and the client isn't abusing a child, all you've done is hurt the client. That client will never go back to another therapist after having the police show up at their door.

Confidentiality issues become more complicated when you are treating children from a divorced couple and there is a noncustodial parent, custodial stepparent, and a noncustodial stepparent. Who gets to hear what, and what do I do to protect my client from a parent who might use that information against the other parent? This is one reason why many clinicians have stopped seeing children. There's too much to sort out and too much extra-therapy time required to deal with all those relationships.
b. Dual relationships. If I am seeing a client for therapy, it is my obligation to avoid any other relationship with the client. So, for example, if my client fixes furnaces, I don't hire him to fix mine. Think of how therapy would go if the client does a bad job for me.

The worst example of dual relationships involves clinicians who have sexual relationships with their clients. It's a felony in Pennsylvania, yet it still happens remarkably often. Hollywood seems to think there's nothing wrong with it, which is really bizarre, given the amount of therapy taking place there. There were some recent jokes on TV about it, which really offended me.

Even dating a client years after you have terminated therapy is a terrible idea, although in some instances, it's considered ethical. Personally, I don't see how you can have a relationship with a former client that is truly egalitarian. There would always be some remnant of the old theraputic relationship there.

For those of us in small communities, simple decisions can raise problems with dual relationships. For example, say I want to buy an Accura. The only dealer in town is a client of mine. Do I go to the client's dealership (in which case, he can look at my credit history—another can of worms), or do I go out of town? How do I explain that to my friends, without revealing my relationship to the client, or implying there's something wrong with the dealer? Imagine if that gets back to the client.

c. Payment for services. When clients lose their health insurance or if their benefits run out, the clinician is left in a quandry. Referring long-term clients away to a county agency can be traumatic for the client, evoking old fears of abandonment. When I was in private practice, I might decide to see someone pro bono. That's a lot harder to do when you work for a large corporation with specific ideas about the bottom line.

The flip side of payment issues is productivity. Most employers today expect psychologists to produce a quota of charges for the week. The quota has been rising over the years. A long time ago, the American Psychological Association defined a full time caseload as 20 clients a week. As costs have risen and reimbursement has lagged, caseloads have risen.

Currently, it is expected that you see somewhere in the vicinity of 28 or 30 clients per week. That means that you are seeing at least 6 people per day in a 40 hour week. That is certainly doable, but it's very tiring. The last client of the day may not get the best services. At what point does the large caseload become an ethical issue?

Professional ethics are, by their very nature, a minefield. A middle aged psychologist once remarked to me that her only ambition was to make it through to retirement without getting sued. That's a pretty low level of ambition, particularly because the odds of being sued are pretty low, despite the minefield we have to negotiate every day.

When I started into private practice, malpractice insurance cost $150 a year. Today, it's 10 times that amount. Still, that's not a bad expense, compared to many other professions. Part of the reason, I believe, is that American psychologists have taken ethics seriously. While the APA doesn't have much teeth to it's ethics committee, the state boards of psychology do.

State boards are run by state governments. Most of them have written the APA ethics code into their professional licensure laws. The boards have teeth and they do bite on a regular basis. Most boards can issue reprimands, fine psychologists, limit or even revoke their licenses, depending on the severity of the infraction. I hear a lot of complaints about them from other psychologists, but the Boards keep us on our toes. They've made us more responsive to our clients' needs. Last year, in Pennsylvania, according to the Board of Psychology newsletter, only 11 people were disciplined, so in this state, that's not much of a risk.

State boards are only one kind of landmine. The other is the malpractice suit. This, fortunately, is very rare. I believe (I could be wrong here) that the probability of a clinical psychologist being sued in the course of a lifetime is about 2%. Those are pretty good odds. However, I hear from others who have been sued that it is a terrible experience, as it is when you're disciplined by the board.

Ultimately, ethics are about good practice. Keeping up with the latest literature, maintaining confidences, consulting other clinicians when in doubt, are all ways of providing good treatment and keeping yourself safe from malpractice. You can't be 100% certain of avoiding a suit, but you can keep yourself reasonably safe.