Just Noticeable Differences

Conflict within the Autism Community

2010-03-28T12:24:00.002-04:00

President Obama has nominated Ari Ne'eman (pronounced AH-ree NAY-men) to the National Council on Disability, and in the process has inadvertently highlighted a split in the Autism advocacy community. Ne'eman is an interesting guy. He apparently has Asperger's disorder and is the Founding President of the Autistic Self-Advocacy Network (ASAN). They argue that autism is a form of "neurological diversity." By conceptualizing autism in this way, ASAN sees autism as a form of diversity, not an illness.

ASAN argues that the main focus on autism expenditures should be on providing supportive services and thus finding ways to include autistic persons in society. It shouldn't be on finding a cure. In contrast, the largest advocacy group on autism in the US, Autism Speaks, still sees autism as an illness that needs to be cured. They want to see an emphasis on research on causes and cures. The New York times just published an article on the controversy.

From my perspective, as a clinician who has worked with persons with autism, the controversy is overblown. The reality is this:

First, advocates of the neurological diversity hypotheses about autism should remember that the vast majority of mutations occurring in the natural environment are maladaptive. There is no reason to assume that all diversity is good and this is the case with autism. The social and economic costs of having a child with autism in the family are tremendous and we should not idealize autism. Families are disrupted. There are divorces, because parents are depressed and guilty about the child. Siblings often feel left out and lost in the family while parents devote most of their energies to the disabled child. Autism can be a terrible disability. We have found that early intervention does have a positive impact on autism, but we are still a long way from a cure.

Second, there is a wide range in the functioning of autistic persons. People like Ne'eman can function fairly well and be remarkably successful. However, they are the exception to the rule. Most autistic individuals are unable to function independently and--if they can work at all--can only do manual labor. While there is nothing wrong with manual labor, people with autism simply do not have the social skills to function adequately in those kinds of situations. I know. I work in an county that still has a lot of factories. A person who is "different," perhaps in appearance, ethnicity, or functioning, gets horrible harassment, especially if they don't have the social skills to stop it. A factory or construction site is not a place for people with autism. There are few jobs out there for them in the community.

Finally, our current commitment to housing and social resources for people with autism is pitiful. It takes years to be placed in supported housing in Pennsylvania. I assume it is the same in other states. Care providers in group homes are terribly underpaid and there is a tremendous turnover in employees. The greater the turnover, the less the experience of the average care provider, and the worse the care is.

Ultimately, given our limited resources, we have no choice but must divide them:

We need basic research to better understand the causes of autism, which we hope will lead to either a cure or prevention or both.
We need treatment research to improve our current assessment and treatment protocols.
We need more social services to provide more support so that we do not abandon persons with autism.

Obviously, I'm arguing that both sides are right and I don't apologize for that. Advocates of each side can deny the legitimacy of the other side. But in the long run, treating autism is an overwhelming task and no amount of denial will make it less overwhelming. Compared to the need, our resources are very limited. Is it hopeless? No, but solving the whole puzzle of autism will take much time and many more lives are going to be impacted by it before then.

There is a book of Jewish wisdom, entitled Pirke Avot, which is variously translated, "Ethics of the Fathers," or (more modernly), "Teachings of the Sages." One of my favorite teachings comes from Rabbi Tarphon, who said, "You are not required to finish the job, but neither are your free to abstain from it." He was talking about religious study, but his advice has also been interpreted as applying to doing good works. As a society, we need to live by that wisdom, especially as it applies to all forms of disability.

We Won! (For the Time Being)

2010-03-22T18:02:00.003-04:00

Last night, the Democratic Party won it's fight to reform health insurance. You'd think it was over, but it's not. The Republicans have sworn to repeal this legislation.

So, first, there will be another endless round of parliamentary maneuvers in the Senate to delay passage of the budget reconciliation bill. That will eventually fail, but in the meantime the Democrats will go through another round of shooting themselves in the foot by arguing over the bill.

Then comes the November congressional elections. At this point, the whole electorate will be fed up with the whole thing. This, however, won't stop the Republicans from lying about something else and continuing to stir up the pot. If the Democrats play true to form, they won't anticipate what the Republicans are going to do and will get caught flatfooted. They'll have to say such things as, "No the new health plan won't require you to get your nose pierced," while Fox News will swear up and down that it does. So, here's what I recommend:

First, by the November, some of the provisions will be in place. Democrats should spend the next seven months all over the news showing people what is really happening. Point out that if you like your insurance, nothing's changed. Point out that people in the high risk group have finally gotten insurance and can breathe easier.

Second, the Democrats should immediately and loudly and repeatedly portray Republicans as people who are perfectly happy with millions of Americans being without insurance. Put the Republicans on the defense for a change.

Third, don't throw numbers like "40 million" around. Instead say, "one in six Americans are without health insurance." Think about what that means the next time you're in McDonald's.

Finally, make them out to be the obstructionist, sore losers they are.

Make the debate about the Republicans and you'll win in November. Make it about health insurance and you'll lose to their next round of lies.

Health Care Hangs in the Balance

2010-03-06T13:00:00.003-05:00

Well, here we are again, wondering what will happen to health care reform. It is amazing that we're still watching the Democrats fumbling around when there is a clear path to success.

Before Howard Dean took over as chair of the Democratic party, I used to say that Republicans are a bunch of vicious hypocrites and Democrats are a bunch of fumbling incompetents. Then Dean launched his 50-state strategy. I watched Obama run a great campaign and the Democrats in congress got majorities in both chambers. So I stopped saying it. Unfortunately, now that Dean has completed his tenure, the Democrats went back to their old ways.

So, in the hope that Democrats still have some potential, here's my message to those of them who are still on the fence about health care:

This is why you became a Democrat. Democrats believe in the ability to government to help people. Democrats believe that government should help everyone, not just the wealthy. Here's your chance to act like a Democrat.

Failing to pass health care reform will make you look inept. That's what the Republicans are counting on. Don't worry about people voting against you for passing health reform. They didn't vote for you in the last election. Worry about people who will vote against you for your legislative incompetence.

You'll show Republicans they can lie and get away with it. Do you think they'll stop lying if health care reform goes away? NO, YOU IDIOT!! THEY'LL SEE LYING WORKED AND LIE MORE!!

Don't be afraid of Republican lies. They lie because the facts are against them. Otherwise, they wouldn't have to lie. Don't be afraid to call out the Republicans on the their lies and don't be afraid to answer their lies with the facts. Just learn to make the facts understandable. Say it over and over and people will get it.

I promise I'll vote for you if you support health care. I know I'll regret this, but I mean it. I dislike both my senators (Specter and Casey) immensely. But I'll vote for them in the primary and general elections if they can deliver on health care. Screw this up, and I'll vote for Felix the Cat first. This is especially true for you, Bob Casey, if you get sucked into the anti-abortion mess.

The Senate bill is imperfect but it is still better than nothing. I'd be happy to see the public option in there. Hell, I'd like to see a single payer system, but I know it can't happen in the US. But since you can't make a perfect bill now, this will do. You can make the system better in the future, even without a single payer system, and maybe without a public option.

Don't be afraid to use the budget reconciliation process. The Republicans used it to pass their tax cuts for the wealthy. You can use it, too. Make the Senate bill better with it. The fact that Republicans are yelling (and lying) so hard about it tells me they're scared. GO FOR IT.

Don't worry about Republican hand wringing over the deficit. Instead, counterattack. It was Republicans who ran up the deficit with unwise tax cuts and two unfunded wars. They were the ones that created the economic mess we're in with their opposition to effective regulation of Wall Street. Economists will tell you that the deficit is not out of control, especially because interest rates are so low. Answer Republican lies with the facts.

Health care reform is good for the economy. From reducing lost wages to reducing illness-related bankruptcies, better and more affordable health care is good for the economy. More affordable health care means more small business start-ups. Small business almost always fuels economic recoveries.

Don't be afraid of a Republican filibuster on this or any other bill. Make the Republicans do it. Let voters see the spectacle of them staying up all night holding up the work of the Senate.

Stop trying to get a bipartisan bill. In AA, they define insanity as doing the same thing over and over again and expecting different results. Get some sanity. The Republicans aren't going to help you.

And pass the damned bill!

Is Health Care Reform Going to Fail Again?

2009-08-01T16:33:00.005-04:00

I've been watching the debate over health care reform and I'm losing hope that it will happen. People of good will can disagree about the best way to deliver health care to all Americans. But, we're not seeing that. Instead, the debate is about nonsense. Things like:

You're going to substitute socialized medicine for my Medicare! (No, Medicare IS socialized medicine and nobody is trying to mess with it.)

You're going to make health care elitist, so only the wealthy will have good health care! (No, the way it is now, only the better off can get good health care. Obama wants to make it less elitist.)

The government will withhold health care and let old people die! (No, nobody has proposed that and nobody would tolerate that.)

An anonymous bureaucrat will control my health care! (What do you think is happening now? With public health care, you can write to your congressman. Under the current system, you get to write to the company that denied you coverage.)

It's going to be too expensive! (No, doing nothing is too expensive. Nobody has argued with President Obama's point at his last press conference, that doing nothing will double our health care costs in ten years, while further reducing the number of people covered.)

I won't have the freedom to choose my health plan! (You don't have that freedom now. Your employer selects the plans you get to choose from. If you're lucky, the plan you can afford is adequate. If we have a "public option," that plan will be available to everybody, actually increasing choice.)

I won't have the freedom to choose my doctor! (The way it is now, you have to choose a doctor who takes your plan. If your employer decides to change your plan, you might have to change doctors. That won't change unless regulations require insurance companies to accept all willing providers. Fat chance.)

I won't be able to keep my current plan! (Yes, you will. There is nothing in any of the current proposals to keep you from doing that.)

I'll be forced to buy insurance when I don't want it. I should have the right to go without insurance! (No, we're all in this together. You never know when you'll fall down the steps, get bitten by a mosquito carrying Lyme disease, or be diagnosed with cancer. Just like with car insurance, you pay into the system so you can get the benefits when you need them.)

The health insurance companies like the system the way it is. They're making money hand over fist. They don't want any changes and they are throwing money at both parties (1.4 million dollars a day!) to defeat reform.
Worse yet, the Republican Party has decided that defeating Obama is more important than helping US citizens. They have been actively feeding this nonsense through their usual media outlets. They ought to be ashamed of their lies, but I don't think they have the moral fiber.
There is no reason we should be holding to the current system. It's a social and economic mess. People are going bankrupt with medical bills, while others have no coverage at all and only get treatment at an emergency room when they are really sick. Furthermore, we cannot compete internationally if we continue to throw good money after bad for health care.
Every other western nation has managed to provide health care for all its people. Why can't we? There's only one reason we can't: We've got Republicans and they don't.
Blue Dog Democrats are bad enough, but at least they're willing to vote for something. If health care reform fails it will be on the Republicans, and they will happily take the credit. But, while they are celebrating, they should know there will be a lot of us who will remember what they did.
I guarantee you, if health care reform fails, the only time I'm going to vote Republican is for dog catcher. Then I'll get the meanest, nastiest dog I can find and set it loose.

How Health Care Reform can Save Money

2009-06-30T12:06:00.018-04:00

Health care reform is near and dear to my heart, both as a provider and as a patient. The national situation, where 40 million Americans either have no health insurance or bad health insurance, is an abomination. Under Obama, it looks like some kind of reform is going to happen now. I've been wondering about some more obscure aspects of the system.

The Senate Health, Education, Labor, Pensions (HELP) committee has released an outline of its latest proposal for for health care reform. I just found the bill on their web site. It's 615 pages, so I don't think I'll be reading it between clients. I skimmed over it, and didn't see what I was looking for.

I was specifically looking for reform of programs that have health insurance components, such as:

Worker's (or Workman's) Compensation insurance;
Motor vehicle insurance;
Medical malpractice insurance;
Homeowner's, renter's and business liability insurance; and
Product liability insurance.

You could probably come up with some additional examples, but these seem to be the major insurance programs. All of them deal with injuries which are attributed to the fault of another person or entity. Under these plans, medical costs attributable to the accident are not paid through the person's medical insurance. They are paid by the appropriate liability insurance company.

So, for example, a worker injured on the job is compensated by the employer for his or her injury through Worker's Compensation. Injuries from slipping on a wet floor at the supermarket are paid by the supermarket's liability insurance. An injury caused by a defective product is paid for by product liability insurance. Here's the critical thing: While the person's initial claim may be covered quickly by the insurance company, escalating costs are fought vigorously. The only thing an injured person can do is hire a lawyer.

Universal health care can reduce some of these costs, but my reading of the bill says it won't. This is a shame, because one of the goals of insurance reform is to reduce costs to businesses. Let me show how it can do this. First, as an example, consider worker's compensation:

An employee is hurt on the job. He goes to the emergency room as instructed by his employer and gets initial treatment. Then, he goes to other physicians or therapists as appropriate and takes some time off to recover. Ideally, Worker's Compensation would cover the medical costs and the lost wages.

"Ideally" is the operative word. Worker's Compensation insurance will cover the employee's claim only if they are convinced that the injury is genuine and a direct result of the employee's accident. They fight the claim if there is any ambiguity in the diagnosis or if there is any reason to suspect a preexisting condition. There is always ambiguity and there are frequently preexisting conditions, so a large number of Worker's Compensation claims end up in litigation.

The whole thing can take years to resolve. During this period, the employee is subjected to extensive harassment and intimidation. I have heard all of the horror stories, and I've heard them repeatedly. The first time you hear them, you think the person is paranoid. But then you hear the same stories again and again, and it no longer seems delusional.

For example, a person receiving Worker's Compensation benefits finds that, with no good reason:

The person goes to a pharmacy to refill prescriptions. The prescriptions, which were covered a month ago, suddenly aren't being covered. There's a $500.00 bill to be paid before they get their pills.
The monthly check covering lost wages stops coming without warning.

Frantic phone calls go unanswered until the person retains an attorney, and then magically the benefits start up again for some period of time. Then, other things start happening:

The person is followed and videotaped by private investigators to find evidence they're not disabled. Investigators are allowed to videotape through the person's windows and show the tape in court.
The person is sent to a physician, sometimes far away from their home, whose sole job is to review the claim, perform an examination, and proclaim they are ready to go back to work.
Hearings over eligibility for Worker's Compensation are scheduled far in the future and then continued for no good reason, often leaving the person without a check or without medical care.
Needed treatment is denied after a long decision-making process. Often this means that more extensive and expensive treatment, with poorer results, has to follow after the claim has been resolved.

I would rather find out that a nuclear cruise missile has been launched directly at my rectum, than to go through this. Of course, that's the point.

For Worker's Compensation companies, there is no downside to this level of harassment. The more they harass you, the more you get worn down, and the quicker you are to settle. It's expensive, but the costs are just passed on to the employer, who is reassured that they are really saving money because none of their employees are (God forbid!) getting over on them.

My experience has been that Worker's Compensation has been the worst of these systems, but this can happen anywhere when liability for medical care is involved. I've seen it with motor vehicle accidents, and have heard about it with medical malpractice and product liability cases.

We all pay for this crazy system. We don't pay it up front, and the costs are hidden, but they are there. When you buy a car, a refrigerator, or a can of soup, part of that cost covers workers compensation and product liability insurance. Similarly, when you pay your car insurance premium, part of that premium pays for health care costs for injuries others have sustained in an accident. The price you pay for food or for a swing set partly covers these costs. Your health insurance premium partly pays for medical malpractice and workers compensation for health care workers.

So here's my question: If health care is a right, not just a perk provided by your employer, why not just include the treatment of all injuries under it, regardless of origin? That way treatment is administered in a timely manner and without difficulty. There will still be litigation over lost wages, pain and suffering, and lost capabilities, but at least health care will be out of the picture.

I can hear the demagogues bellowing, "I don't want my health insurance to pay for someone else's mistakes!" Well, as I just indicated, you pay for it anyway. You just pay for it with a different check. And you pay more for it because you have legal fees attached to it. We can streamline the process and reduce costs by eliminating the adversarial system as it covers health treatment.

Will people try to run up health costs to appear more disabled than they really are? Of course they will. But however health care reform works, there will be cost controls in place to handle unnecessary treatment. Those cost controls are much less expensive than litigation.

How much less expensive is an open question. I haven't been able to find statistics on how claims break down into medical vs. non-medical payments. One site I found wanted $500 for access, so I'll leave that issue to others who have better library access than I do. I would love to hear from you if you do have that data.

By removing medical coverage from worker's compensation and various liability insurances, we reduce costs to employers and manufacturers. We have heard about tort reform for years and it is usually a code for "let's screw the little guy." This is a simple tort reform that has the potential to significantly reduce costs and will benefit the little guy at the same time. It makes our products more competitive on the world stage and that cannot be a bad thing.

Grieving for our Parents

2009-04-26T12:53:00.002-04:00

This week's New York Times Magazine has a fascinating article by Christopher Buckley about the deaths of his parents, Pat ("Mum") and William F. Buckley ("Pup"). The article, excerpted from his upcoming book, is about his ambivalent relationship with them. Christopher is a wonderful and compelling writer. He tends to write in a style we clinicians call, "rambling, but goal-directed." He often digresses, but there is always a purpose to it, and returns to his main point quickly. He is an apple that didn't fall far from his parents' tree.

Christopher's mother died 11 months before his father. He relates seeing her in the ICU. At a point when she may have already been dead, he found himself saying, "I forgive you." Like so many essential things we say, his words surprised him. Then, a few months later, with his father facing death, they had this interaction:

I had planned to leave mid-July on a trip to the West Coast. One night as we watched the first of three — or was it four? — movies, he said apprehensively, “When are you leaving for California?”
“I’m not, Pup. I’m going to stay here with you.”
He began to cry. I went over and patted him on the back. He recovered his composure and said, somewhat matter-of-factly, “Well, I’d do the same for you.”
I smiled and thought, Oh, no, you wouldn’t. A year or two earlier, I might have said it out loud, initiating one of our antler-clashes. But watching him suffer had made my lingering resentments seem trivial and beside the point.
I wondered, while keeping this vigil with him, whether to bring up certain things and talk them out so that, when the end came, nothing would be left unsaid between us. But each time I hovered on the brink, I found myself shrugging and saying, Let it go. Perhaps it was another way of saying “I forgive you” — as I had to Mum that night in the hospital — on the installment plan. I felt no need for what is called, in other contexts, the “exit interview.” I was able to love him now all the more, and actually laugh (inwardly, anyway) at that “I’d do the same for you.” Oh, yeah? Ho, ho, ho.

We come to terms with a loved one's death by accepting them as they are. It is at best unnecessary, and sometimes counterproductive, to try to leave everything said, or to "talk things out." Instead, we need to understand that in the face of death, "my lingering resentments seem trivial and beside the point."

When we grieve for our parents, we grieve for them as they were, and we grieve for what we have wished they were. As we come to terms with that discrepancy, we come to terms also with our own lives. We do not have to be perfect to be valuable human beings. Our past mistakes and our current faults do not make us despicable; they make us unique and human. In some ways, Buckley is telling us, our faults are just as precious as our our assets.

The Psychology of Jealousy: Guest Post

2009-04-18T18:48:00.002-04:00

I recently had a request from Sarah Scrafford, to post on JND. As I haven't been posting lately, I welcomed her offer. Below are her thoughts on the psychology of jealousy.

The Psychology of Jealousy

Relationships are complicated, even when things are going smoothly. You never know when you’re going to be overcome by emotions like anger, sadness, and the worst of them all, jealousy. It’s an evil, green-eyed monster that makes your life miserable; it eats away at every shred of happiness you have until you’re a bundle of nerves and an emotional mess; and it makes you do things you would never do when you’re in your right senses. We only have to look at the female astronaut who put on a diaper and drove all through the night to attack a rival for her beau’s affections to see the truth of this statement.

A close friend and I were discussing a couple whose relationship had hit the doldrums. He wanted in, she wanted out; and the more she wanted out, the more he wanted in. My friend was of the opinion that that’s the way human beings are – when we know that we cannot have something, we somehow seem to want it even more. So when someone close to us withdraws and retreats into a shell, we seem to crave their company and affection in the worst possible way. It’s worse when there’s a third person involved, when you know that someone else is getting what you think you deserve. Jealousy comes rushing in and takes over your life, making you incapable of rational thought or reasoning.

While I’m no psychologist, here’s what I know about the psychology of human relationships – the best way to attract someone’s attention is to pretend to be totally unaware of them. This works really well when they know you’re interested in them and when they’ve rebuffed your advances at least once. The moment you stop hanging around them or trying to get them to show an interest in you, they’re going to wonder why you changed your mind, why you’re not as into them as you seemed to be before. And this hits their ego, the one that you helped inflate with your undivided attention.

If they’re the mature kind, they realize this hurt ego for what it is and let things go; after all, they’re really not interested in a romantic relationship with you. If not, they’re definitely going to hang around you more, check if you’re looking at them from afar, tease you a little with a text message or a mildly flirtatious email, or invite you out for a cup of coffee. But before you jump for joy at this new attention, let me warn you that this interest, the one that’s riding solely on a hurt ego, will disappear the moment you begin to reciprocate, unless your beau is really into you by this time.

Yes, as Shakespeare rightly said; it’s a tangled web we weave, when we first practice to deceive. The psychology of relationships is complicated, more so when we have to play games to win over the people we really want.

This article is contributed by Sarah Scrafford, who regularly writes on the topic of online radiography schools. She invites your questions, comments and freelancing job inquiries at her email address: sarah.scrafford25@gmail.com.

Traumatic Brain Injury and Football

2009-01-28T09:37:00.002-05:00

Almost exactly two years ago, I posted a sports rant focusing on the effects of repeated concussions on football players. Here it is Superbowl time again, and another story has surfaced on the topic. (Also see here.) I assume these stories are released at Superbowl time to get more play.

The study of the brains of former NFL players is being conducted by the Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine. Credits are as follows. I added the parenthetical clarification of the acronyms:

CSTE (Center for the Study of Traumatic Encephalopathy) is a collaboration between SLI (Sports Legacy Institute) and USM (Boston University School of Medicine). SLI was founded by former Harvard football player and WWE pro wrestler Chris Nowinski, and neurosurgeon and concussion expert Robert Cantu, MD, chief of Neurosurgery and director of Sports Medicine at Emerson Hospital in Concord, Mass, and clinical professor Neurosurgery at BUSM. The work at BUSM is being led by McKee, an associate professor of Neurology and Pathology, director of the Neuropathology Core of the BU Alzheimer's
Disease Center, and the director of the brain banks of the Framingham Heart Study and the Bedford VA Medical Center, and Robert Stern, PhD, associate professor of Neurology and co-director of the BUSM Alzheimer's Disease Clinical and Research Program. The CSTE received initial funding for their research from BUSM and subsequently received a $100,000 grant from the National Institute on Aging to support their work. This past week, the group of researchers learned that they received a $250,000 grant from the National Operating Committee on Standards for Athletic Equipment (NOCSAE).

According to the story, players have been asked to donate their brains for study under the "88 Plan," named for John Mackey who wore jersey 88 for the Colts and now has severe dementia. So far, 7 NFL players have been evaluated, an 6 have been diagnosed with chronic traumatic encephalopathy. Trauma refers to damage. Encephalopathy refers to brain pathology. Hence, traumatic encephalopathy is a technical term for brain damage caused by head injury.

One can diagnose encephalopathy through brain imaging, psychological tests, and by clinical signs and symptoms. However, in this case, the diagnosis was made the most reliable way, by autopsy, so there is no mistaking the severity of the problem. Interestingly, the players' brains had some similarities to Alzheimer's patients. Most of the players showed signs of memory loss, impaired thinking, depression, and impulsive behavior. They also may have abused substances. Two died of suicide and a third died of a self-inflicted gunshot wound ruled accidental.

This is pretty scary data, but I want to add two cautions to interpreting the data. First, these are people who have died early, between 25 and 50, so they had severe and repeated injuries. If we examined players who lived a full life, we would certainly see a different picture. This is why the authors have carefully avoided claiming that most NFL athletes have brain injury.

Second, the players with traumatic encephalopathy played at a time when concussions weren't taken seriously. The NFL has developed procedures for managing concussions and when to allow a concussed athlete back onto the field. The NCAA has supported studies of concussions. The American Academy of Family Physicians has a nice summary of how to manage concussions in high school athletes. As mentioned above, the quality of the equipment is also being evaluated. So, now that concussions are being taken more seriously, the pervasiveness of traumatic encephalopathy should be declining. But we don't know that for sure.

As someone who spends most of his time in his head and others', I question why we accept this risk at all. Remember the old commercial, "A mind is a terrible thing to waste"? When a child or a young adult athlete is concussed, the rest of their life is at risk. And for what?

Controversy over DSM-V

2008-12-20T15:35:00.003-05:00

This week, I finally got a reprieve from numerous reports and paperwork, so I can dust off the old blog and have some fun again. There is no better place to begin than the controversy over DSM-V.

Background

First, some background. DSM-V stands for Diagnostic and Statistical Manual--Fifth Edition. Of course, in psychiatry, numbers can be misleading. DSM-V will actually be the seventh revision, as DSM-III was revised once (DSM-III-R) and DSM-IV was also revised (DSM-IV-TR. TR stands for "Text Revision.") It's published (and jealously guarded) by the American Psychiatric Association.

When I started out in the 1970's, DSM-II was the manual we used, and it was awful. Definitions were vague, and you could diagnose the same person with anything from depressive neurosis to schizophrenia without much difficulty. DSM-II was generally denounced as irrelevant and unnecessary by behaviorists and humanists. At the time, diagnosis had little to do with treatment, so it really was unnecessary. In hospitals, physicians would argue endlessly about a patient's diagnosis, with no change in treatment after they had differentiated what kind of schizophrenic they were dealing with.

DSM-III changed all that, as diagnoses were made on the basis of behavior. Specific symptoms were identified and you had identify a certain number of symptoms in order to diagnose depression. This was a great advance in two areas. First, research could be focused. If you wanted to research a treatment for depression, there was now a clear operational definition for depression. That means that we could compare different studies without comparing apples and oranges.

Second, DSM-III gave us the ability to communicate what we were treating to third parties. It was published when insurance companies were beginning to pay for psychotherapy. Unfortunately, many therapists didn't know an adjustment disorder from major depression. Consequently, managed care used DSM-III to refuse to pay for many treatments. We had to learn to say, "Here are the symptoms that show the client is depressed and here is the progress I am making on them. Once we learned to do that, managed care stopped refusing psychotherapy and we now generally get as much time to treat clients as we need.

The Controversy

DSM-IV has been a small improvement over DSM-III, but it's still controversial. Now DSM-V is on the horizon and it's generating more heat. A recent article in the New York Times picked up on the controversy. There are a number of points of controversy.

First, there is no real understanding of the causes of mental illness. We're still not even sure if there is such a thing as a mental illness. Psychiatry has been moving toward a neurobiological model of mental illness, but is still far away. If you ask a psychiatrist what causes depression, you'll hear one of two answers. You might hear, "We don't know," which is the honest answer. However, more likely, you will hear some mumbling about serotonin and biochemical imbalances. Those guys are just blowing smoke. Just ask them to define a healthy biochemical balance; their response will be entertaining. Unfortuantely, more than half of the members of the task force writing DSM-V have drug company connections, so you know they will remain committed to a neurobiological model.

Second, diagnoses are often points on a continuum. Consider what is now called Attention Deficit/Hyperactivity Disorder (ADHD). Our ability to pay attention falls along a continuum from fleeting to intense. When we diagnose someone with ADHD we are saying that their attention on the average, falls below some imaginary point on that continuum. That imaginary point is also arbitrary. Do we abandon children who fall just to the normal side of that point? How about children who fall mostly to the average side of that point, but occasionally their attention and concentration crash and burn?

Third, the inclusion of a diagnosis in the manual has always been unsystematic and has many social implications. Why is repetitive handwashing considered obsessive compulsive disorder, while repetitive shopping is not? Is binge eating a disorder, or does the person just need to grow up and get some self control? In DSM-II, homosexuality was considered a diagnosable mental illness. In DSM-III, homosexuality was removed as a diagnosis. There is a straight line from deciding homosexuality is not a mental illness to deciding gays should have the right to marry.

Fourth, how open should the process be? The APA has had the members of the DSM-V task force sign conficentiality agreements. Dr. Robert Spitzer, a member of the APA task force on DSM-V has raised concerns about it. (More about the controversy can be found here.) Given the social implications for some diagnoses, there's a lot at stake here. But, it's difficult to balance the need for open, scholarly discorse, with the risk of being personally attacked by one pressure group or another.

Who gets treatment is affected by diagnosis. When I diagnose a child with autism, that child becomes eligible for a wide range of services that a child with plain old "mental retardation," would not get. Interest groups in a lot of areas would like to see their own diagnoses included, so more services become available. A battle is raging over whether or not transsexuality should be included in DSM-V as a mental illness. Some would like it to be normalized; a person should be able to cross dress if they want to. However, others would like to have insurance cover sexual reassignment surgery. You can't cover a procedure if it isn't treating a diagnosis.

Conclusions

DSM-V will almost certainly move closer to a neurobiological model and away from a psychosocial model. That will lead to less emphasis on psychosocial treatment. I don't hold that against psychiatry; they treat mental illness biologically. However, psychotherapy still has much to offer. Psychotherapy is still the best (or at least a competitive) treatment for personality disorder, post-traumatic stress disorder, and some depressive and anxiety disorders. Generally, psychotherapy reduces the risk of relapse. Yet, if we structure our diagnoses around neurobiolgical models, psychotherapy will be marginalized. Already, family and marital therapies are extremely difficult to justify using DSM-IV. Somehow, diagnoses should also be there to allow for psychosocial treatment and to encourage more research in that area.

Despite these problems, we still need a diagnostic manual. Psychiatric diagnoses, for all their arbitrariness, give us a way of organizing research and communicating therapeutic information. At some point research will give us a handle on the nature of mental illness, and a clear diagnostic system will emerge from that. In the meantime, this is the best we've got, and none of the critics have given us a good alternative to the writing of a new manual.

APA Passes Resolution Passes on Psychologists' Working in Detention Settings

2008-09-17T18:18:00.003-04:00

The American Psychological Association has just issued a press release stating that the membership passed a resolution forbidding work in settings where "persons are held outside of, or in violation of, either International Law (e.g., the UN Convention Against Torture and the Geneva Conventions) or the US Constitution (where appropriate), unless they are working directly for the persons being detained or for an independent third party working to protect human rights."

The full text of the petition is here.

If I read this right, there are no significant loopholes. Psychologists should either work for detainee's well being or not at all.

It's about time!

I think some people thought that there was room for psychologists to work within the system to better the detainees' situation. I don't believe that's possible. While it's enticing to think of the heroic psychologist fighting the system, human nature (not to mention Solomon Asch and BF Skinner) tells me that the psychologist would just be co-opted into the system.

It was also particularly galling that the AMA had done this long ago while the APA wimped out. So, as I often teach my clients, time only goes forward. It would have been better for APA to have done this sooner, but doing it today is better than doing it tomorrow.

JND in Top 100 Mental Health and Psychology Blogs

2008-08-16T13:17:00.003-04:00

Just Noticeable Differences has been mentioned in the Top 100 Mental Health and Psychology Blogs. It is an interesting site, and I found some good stuff there. I appreciate the mention, especially when I haven't blogged since May. My goal this year was to blog weekly, and I haven't come close.

I have been extremely busy. Work has gotten chaotic and I have been spending all my free time at home either working on the house or, more often, writing reports. After you've spent several hours on a weekend writing such deathless prose as, "On examination, Mr. Johnson was alert and oriented in three spheres," blogging isn't high on the list.

There are several reasons work has gotten chaotic. First, as I've said elsewhere, fees for psychotherapy services are static. I will get a 3% raise soon, but with inflation about 5.6%, I will still still have to work more hours to stay even.

Making matters worse, there has been a lot of conflict in my office. I think it's due mismanagement, but hey, nobody listens to me, anyway. At this point, I'm so disgusted that I'd like to leave and restart my private practice. Unfortunately, I am the source of health insurance in my family and I would have to purchase insurance separately if I resigned. I calculate that if I and my wife were lucky enough to qualify for it, we would pay through the nose. There is also no guarantee that if we got sick and tried to use it we would be able to keep it. So, isn't this great? I get both ends of the health insurance mess at the same time.

I've learned one critical lesson from this. Republican opposition to national health insurance has nothing to do with taxes or small government or any other nonsense. Republicans oppose national health insurance because it makes employees more dependent on their employer. Because I can't just pick up and start a private practice, my employer has more control over me.

Like many Republican policies, this is at best penny-wise and pound foolish. At worst, it is self defeating. Opposing national health insurance helps the large corporations, but it hurts the US economy. The lack of national health care almost certainly hinders small business formation. Small businesses are an important part of our economy. It is small businesses that bring innovation into the marketplace.

So, I'm watching the campaign very closely this year. Having a Republican in the White House will probably mean 4 more years of this nonsense. Unfortunately, Obama has apparently inherited the Dukakis strategists: McCain is beating up on him and he's on vacation.

Net Neutrality

2008-05-20T00:02:00.004-04:00
A few years ago, an idea was floated by the large ISP's that they should be allowed to prioritize the access to different web sites. The initial plan was focused on providing faster access to users for a fee. While that idea sounds logical, the devil is in the details.

High volume users, such as Google, have objected strenuously. It will certainly make their operation more expensive, but more importantly, small content providers who rely on Google will be affected by it. After all, the little guys get their start blogging on Blogger and similar sites. It will be those users who will be affected by increased costs to Google and other providers like them. So, little guys like me could be forced off the net.

Now, I know that losing me wouldn't be a great loss. I'm not controversial and I don't blog much. But losing me, means that you could lose someone more important. Why not, for example, make life more difficult for Daily Kos (who just happens to be blogging on this on May 19, as I am)? This is something that we need to be very worried about. The New York Times, in an editorial today, commented that the ISP's
have realized that they could make a lot of money by charging some Web sites a premium to have their content delivered faster than that of other sites. Web sites relegated to Internet “slow lanes” would have trouble competing.
This sort of discrimination would interfere with innovation. Many major Web sites, like eBay or YouTube, might never have gotten past the start-up stage if their creators had been forced to pay to get their content through. Content discrimination would also allow I.S.P.’s to censor speech they do not like — something that has already begun. Last year, Verizon Wireless refused to allow Naral Pro-Choice America to send text messages over its network, reversing itself only after bad publicity.
So, there is a risk that non-neutral access to the web could result in limiting access to sites that express ideas the corporations don't want. Do you think that will be left-wing or right-wing ideas?

I'm going to share an idea that I've held for a long time. It's a little crackpot, but no one I've mentioned it to has been able to punch holes in it. As I look back over the last century, it seems to me that liberal/progressive ideas flowered at two times: the 1930's and the 1960's. I believe it happened because both eras were marked by inexpensive and decentralized media, allowing the left to reach its audience.

In the 1930's, there was excess printing capacity as newspapers and publishers failed during the Great Depression. Radio was a new medium and small radio stations slowly started up. During this period, the Socialist Party flourished. Labor unions started to take off. Roosevelt's New Deal was inked. But then, during World War II, small newspapers and radio stations fell by the wayside. Both the draft and the defense industries needed bodies, and small radio stations and newspapers were a luxury that couldn't be afforded. After World War II, the remaining radio stations and newspapers started folding into ever larger corporate bodies. Since corporations are politically conservative, outlets for left-wing messages were closed down. Not surprisingly then, the 1950's was a politically conservative era.

In the 1960's, new legislation and regulations readjusted the radio spectrum and required that AM radio receivers also receive FM. This allowed FM radio to come into its own. Small family-owned FM radio stations started gaining listeners. The stations found new content in the music and the left-wing politics of the times. As a result, people heard messages that they would otherwise have missed. Left-wing politics bloomed. But in the 1970's, corporations began buying the small stations, and with centralization, left-wing politics again fell by the wayside.

If I'm right, Ronald Reagan was the Teflon President, not because he was the Great Communicator, it was because he was the Only Communicator. George II similarly got a free ride until the internet really matured. He could hide the coffins coming back from Iraq from television. But now he can't stop pictures of the war from being posted on YouTube and things are looking bad for the Republican party.

The Republicans understand this dynamic. Previously, they make no effort to hide their view that Public Broadcasting is a left-wing voice. They've worked hard to harass public television and have tried repeatedly to shut it down. They have also worked hard to relax the rules against corporate ownership of multiple stations in the same market. With the development of the internet, of blogging, of podcasts, of YouTube, and so forth, communications are again being decentralized. If we, who consider ourselves liberal or progressive, want to keep our lines of communication open, we need the internet.

"Net neutrality" refers to protecting the internet from prioritized access. The Times editorial indicates that several net neutrality laws have been proposed to Congress, but they have gone nowhere. Why am I not surprised? The Republicans don't want net neutrality and the Democrats are too stupid to realize how important it is to them.

Learn more about net neutrality at Wikipedia and at Common Cause. There are petitions to sign at SavetheInternet.com or MoveOn.org.

Autism and Vaccines

2008-03-09T12:14:00.003-04:00

The New York Times has a story on a lawsuit over vaccines and autism. It opens as follows:
Study after study has failed to show any link between vaccines and autism, but many parents of autistic children remain unconvinced. For the skeptics, the case of 9-year-old Hannah Poling shows that they have been right along.

The government has conceded that vaccines may have hurt Hannah, and it has agreed to pay her family for her care. Advocates say the settlement — reached last fall in a federal compensation court for people injured by vaccines, but disclosed only in recent days — is a long-overdue government recognition that vaccinations can cause autism.
“This decision gives people significant reason to be cautious about vaccinating their children,” John Gilmore, executive director of the group Autism United, said Friday.
The government argued that it did not cave in to anti-vaccine hysteria:
“Let me be very clear that the government has made absolutely no statement indicating that vaccines are a cause of autism,” Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention, said Thursday. “That is a complete mischaracterization of the findings of the case and a complete mischaracterization of any of the science that we have at our disposal today.”
So, why did they settle? It's not clear from the news stories, and I don't have access to the settlement. Given the attitude toward science in our government, decision-makers may have decided not to let the facts bother them when their minds were made up. Or, maybe they just decided that they didn't want to put this one in front of a jury that might be controlled by sympathy, rather than science.

To understand the science, you have to understand some background. There are two reasons why people began worrying that vaccines may be causing an "epidemic" of autism. The first is that autism rates have been rising along with vaccination rates. The second is that symptoms of autism emerge at roughly the same time as vaccinations occur. So, it seemed like a logical hypothesis. Thimerosal quickly became the culprit.

Thimerosal is a vaccine preservative, and it contains ethylmercury in very low doses. There had been general consensus that the doses were low enough to be of no concern. However, the safety standards were based on methylmercury exposure, and it was thought remotely possible that there could be greater risk with ethlymercury. Alternative preservatives had been developed and it seemed prudent to eliminate thimerosal. Beginning in 1989 thimerosal levels were reduced in vaccines. The process was completed in 1992.

Because Thimerosal levels have been reduced over the years, a good way to track the effects of Thimerosal exposure is look at rates of autism as they correspond to Thimerosal exposure. A number of these studies (summarized here) have looked at this. Of particular interest is the California study. They looked at autism rates in California from 1989 to 1992, when Thimerosal was being removed from vaccines. Had Thimerosal increased risk of autism, rates of autism would have dropped over the course of the study. Instead, there was no change in the frequency of autism. Since they were relying on practitioner's diagnoses, there was no room for bias (by massaging diagnoses) in the study.

Hannah, the autistic girl in the lawsuit, was a member of the age group in the California study. According to the story, she got 5 immunizations at the same time, but still, she would have been getting lowered doses of Thimerosal, because she was getting them after 1989. Again, overall, Hannah's age group showed no change in it's rates of autism over the course of the study.

As an alternative to Thimerisol, there has also been concern about the measles, mumps, and rubella (MMR vaccine) itself causing autism. Here, the evidence is even weaker. Studies purporting to show a relationship usually involve smaller numbers of cases. They often rely on investigating groups of autistic children and try to relate the emergence of autism with receiving the MMR vaccine. However, as I said before, vaccination occurs at the same age that autism emerges, so you're bound to see a correlation. The only way to identify a relationship here is to examine individuals both with and without autism who have both received vaccinations.

The data just doesn't support a relationship between vaccines and autism. The best explanation for rising autism rates comes from two sources. First, there have been marked changes in diagnosis. We used to see autism as a single entity. You were either autistic or you weren't. Today, we see autism as a spectrum of disorders; you may be more or less autistic. So, people previously diagnosed as mentally retarded are now seen as autistic. High functioning autistic individuals used to be diagnosed with "childhood schizophrenia." Today they're diagnosed with Asperger's disorder, which is considered a form of autism.

Secondly, and perhaps more cynically, diagnostic labels determine access to some services. There are a large range of services for people who are called autistic. If someone's "just" mentally retarded, they may not have access to the same services. Hence, providers may say, "This kid needs Day Training Program A. If I call him 'autistic,' he'll get it. If I call him mentally retarded, he won't." I can't prove this happens, but it wouldn't surprise anyone in this business.

My first professional position after graduate school involved working in an institution for people with mental retardation. I was involved in the group of professionals who made it possible to clear the institutions and get people with cognitive and developmental disabilities living in the community. So, over the years, I've seen a lot. What I've seem mostly, is parents struggling with their disabled children.

As late as the 1960's, the conventional wisdom was to tell parents to put their cognitively disabled children in an institution and try to forget about them. Parents who followed that advice were often consumed by guilt. Today, thankfully, disabled children live and are educated in the community. But it's a terrible strain on the parents and on other family members to have a disabled person in the house. Behavior modification, the best treatment for autism, requires an incredible amount of time and effort. Even so, the guilt hasn't been completely eliminated.

Parents wonder if they caused their child's autism. Was it that drink I had when I was 3 months pregnant? Or that I smoked, or that I chose to have a child at 38? Maybe it was a toxin I was exposed to at work? Maybe I shouldn't have worked? Maybe I should have taken better care of myself?

Wouldn't it be nice if autism was caused by the doctor, and not me?

My heart goes out to parents of disabled children. Their desperation leads to all kinds of ideas; I've seen them come and go. Megavitamin therapy was big for a while. Give lots of vitamins to your autistic child and he won't be autistic any more. Didn't do a thing. Remember assisted communication? The idea was that autistic children had only impaired communication skills and if we helped them communicate they would be just fine. It turned out that the people that helped them communicate were really doing the communication themselves. It's hard to find a good reference to it now on Google.

This doesn't mean we should throw our hands up in despair. As Rabbi Tarphon, a Jewish sage remarked, "It is not required that you complete the job, but neither are you free to abstain from it." We cannot cure or prevent autism yet, but as a community we can support autistic people, their families and other caregivers. We cannot give support by pretending there is an easy cure or an easy explanation for their children's illness.

Ken Pope Resigns from APA

2008-02-09T22:21:00.000-05:00
This story was just emailed to me on the PsyUSA mailing list. Ken Pope, long active in the American Psychological Association, just resigned. His reason for his resignation was the unwillingness of APA to take a clear stand against torturing detainees. I won't bother quoting his letter at all. Ken makes his stand very clear.

I support Ken Pope completely in this. I resigned from APA several years ago because I felt that I was paying too much money for an organization that seemed to have no clear agenda. Ken makes it clear that APA has also lost its moral compass.

Some commentary on Ken's resignation also popped up on Daily Kos. Some of the commenters have questioned why more psychologists haven't resigned. In fact, others have. We don't know how many; they just didn't send out announcements. Other commenters questioned the value of withholding dues as a protest. Personally, I think it's a valid response. They are making their protest known, but they are still part of APA and still have the ability to influence it.

I hope that Ken's action will inspire others to withhold dues or to resign. Maybe APA will finally get the message and follow the lead of the AMA which has forbidden it's doctors to participate in interrogations.

Questions about Psychotherapy

2008-02-09T17:10:00.001-05:00

A recent editorial in the Journal of Psychopharmacology by David J. Nutt and Michael Sharpe raises questions about the efficacy and safety of psychotherapy. It's currently available free of charge, but will be placed behind a pay wall 90 days after initial publication.

Clearly, an editorial in a psychopharmacology journal is not going to be sympathetic to psychotherapy and this article does not disappoint. I'm going to discuss four of their points.

1. Is Psychotherapy Effective?

Nutt and Sharpe begin by questioning the effectiveness of psychotherapy. They say, "few psychotherapy trials have complied with the standard regulations that are required of all drug treatments." This is both true and not true. Psychotherapy cannot be evaluated in the same way as drug therapy. It's a different treatment and there are different issues in evaluating it. Psychotherapy is a procedure, and as such, it is more akin to surgery, than it is to pharmacotherapy.

Nevertheless, psychotherapy has a rich and diverse research base, going back over 50 years. In particular, cognitive behavior therapy (CBT), always grudgingly acknowledged as an empirically based therapy, is based on a large body of literature involving operant conditioning, classical conditioning, rational emotive behavior therapy, self control and self-management. There are large numbers of outcome studies available. While few are large-scale studies, the accumulation of the data through meta analysis still shows fairly robust and positive results.

This research base has given us a good understanding of how CBT works. See the Handbook of Psychotherapy and Behavior Change for some excellent reviews of the research. In fact, we have a better idea of how CBT works than how drug therapy works. We have a pretty good idea about how changing thoughts change mood, and how exposure changes anxiety. In contrast, we still haven't been able to define that "biochemical imbalance" that allegedly causes depression. If you think we have, ask a psychopharmacologist what the balance is, or ask why one SSRI works and another doesn't.

Nutt and Sharpe also raise the issue of whether or not psychotherapy has been evaluated with double blind studies and placebo controls. I'm going to leave that issue for another day. I think they're wrong, but that's going to require more research than I have time for tonight.

Is Psychotherapy Safe?

Nutt and Sharpe question the safety of psychotherapy. They begin by arguing that psychotherapy can, in some cases, worsen outcomes. In particular, they identify suicidal patients and manic patients as being at risk. However, any treatment can cause problems in these patients. We have all heard of the worsening of suicidal ideation in adolescents on SSRI's (Nutt and Sharpe minimize this, but the black box is still there). Less well known is that SSRI's can also cause a manic episode in people with bipolar disorder. One advantage of psychotherapy is that the individual is seen more frequently and can be managed if they deteriorate. In contrast, people receiving drug therapy may not have any contact with their physician for a month or longer.

Another issue they raise involves an old technique called flooding. In exposure therapy, we deliberately expose people to feared stimuli, but in gradual steps. Flooding therapy involves fully immersing the subject in the feared situation all at once. Here is what Nutt and Sharp say about it:
When taken to its logical extreme [exposure therapy] becomes flooding therapy, which was once popular. The anxiety induced by flooding can be extraordinarily distressing and there are well recognised examples of patients escaping in fear from their treatment andrefusing further sessions. David Nutt runs a specialist anxiety disorders clinic in which we have seen a number of patients who could be considered as suffering from a PTSD-like syndrome as a consequence of failed flooding treatment for phobias and OCD. (p.4)
I can believe that a "PTSD-like syndrome" could occur as a result of premature termination of flooding. In fact, I never thought I would have the intestinal fortitude to keep a client in a feared situation long enough to make the procedure work. So, I never did any flooding, and, in fact, I've never met a therapist who ever did any flooding. They must have been out there, but I never traveled in their circles. So, I can't believe it was "popular."

Besides, isn't this an example of the pot calling the kettle black? Shall I now list the now-rejected medical procedures that have hurt people? Ever read the book, The Lobotomist? We who help those in pain often feel the need to "do something," to help people and we often wind up hurting instead of helping.

Nutt and Sharpe then raise the "false memory syndrome" canard. According to advocates of this syndrome, questioning people about past trauma can cause people to develop false memories of events. In reality, experimental evidence for false memory syndrome is weak. Ken Pope has a good discussion of the problems with false memory syndrome here.

Nutt and Sharpe unwittingly provide an excellent example of how badly false memory syndrome is abused. They say:
One young adult patient of David Nutt’s with severe OCD (obsessive-compulsive disorder--F.O.) was quizzed by a therapist about the possibility that she had suffered sexual abuse by family members. This led to her developing chronic ruminations about the possibility that she might have been abused by her father, even though she knew this had not happened. As a consequence for years she was unable to tolerate being in the same room as him, which markedly exacerbated her problems and caused great distress to the family. (emphasis added; p.4)
The section I italicized is the key. The patient knew full well that her father never abused her, so this could never have been an issue of false memories. Instead, this woman was struggling with an obsession. No big surprise. She had OCD. The woman obsessed over the possibility of her father abusing her.

There have clearly been some therapeutic abuses in the name of uncovering a history of trauma. This ain't one of them. A therapist who doesn't consider the possibility of trauma in a severely ill patient isn't doing his or her job.

Are Effective Treatments Withheld?

Moving on, Nutt and Sharpe argue, "Another proven potential risk of psychotherapeutic treatment is that effective drug treatments are withheld either because the therapist does not believe in their efficacy or because the patients are not introduced to the possibility of their being useful in their condition (Klerman, 1991)." True, but this is not a risk of psychotherapy. It's a risk of being a true believer. How many times have patients not been referred to psychotherapists because the physician doesn't believe in it?

Therapist Misconduct

Finally, Nutt and Sharpe bring up the risk of sexual misconduct. They site a 1986 study showing 7% of male psychiatrists and 3% of female psychiatrists have engaged in sexual contact with their patients. I am assuming these are psychiatrists who are providing psychotherapy. But this data is over 20 years old and since then, laws have been enacted, and licensing boards have been aggressive in enforcing a ban on so-called dual relationships. In Pennsylvania, it's a felony to sleep with a client. Yes, I know it still happens. But overall, this isn't a problem with psychotherapy. It's a problem with power relationships. Professors sleep with their students. Business people sleep with their secretaries. This kind of sexual misconduct occurs everywhere there's a power imbalance between men and women. Thankfully, my profession has been aggressive about stopping this.

Conclusions

After all this, I'm not willing to just write off Nutt and Sharpe as a pair of physicians with an axe to grind. I agree that psychotherapy is not as closely regulated as pharmacotherapy and I'd like to see greater quality control over psychotherapeutic services. But like other hands-on treatments, such as surgery, physical therapy, occupational therapy, and others, much of the effectiveness of treatment relies on the skills of the provider. This comes from training. One of the great disappointments to me has been the unwillingness of the leadership in psychology to improve training and accountability.

Psychology defines itself as the science of behavior, and we often research psychotherapy. But, when it comes time to say, "Yes, I believe the data. We should do A and not B to treat depression," we back down and run away. Too many people view any effort to develop treatment guidelines as an attack on psychotherapy. It's a shame that papers like this are so poorly drawn that they reinforce this belief.

Treating Depression in the Elderly: Medication, Psychotherapy, or Both?

2008-01-13T12:18:00.001-05:00

An article in Psychiatric Times discusses the status of treatment for elderly people who are depressed. Written by Mark Miller, it opens with this observation:

There are hundreds of studies that show that pharmacotherapy is used to treat depression in adult and geriatric populations. There are far fewer studies that test the efficacy of psychotherapies and even fewer studies that focus on combined treatment for older patients. This discrepancy is largely a consequence of industry support of research in the former and the dependence on NIMH funding in the latter two. The sober lesson we have learned from STAR*D is that there are no pharmacological treatments that work for everyone.

STAR*D (Sequenced Treatment Alternatives to Relieve Depression) was a massive set of studies, conducted under grants from NIMH, in which they attempted to replicate real world treatment of depression. In the real world, depression often--if not usually--coexists with another disorder, such as anxiety. In most studies, the subjects have uncomplicated depression. That makes it easier to interpret the results, but raises questions about applicability of the results to the real world. In most studies, the subjects were given one medication and evaluated for depression after a set period. In the real world, if the patient isn't responding to treatment, the treatment is changed.

In STAR*D, the subjects were more heterogeneous and they were given sequenced treatment. Hence, the treatment was more applicable to the real world. The results, which Miller summarizes in one sentence above, are, I think, consistent with what all of us practitioners know. Treatment effects are significant, but there is no
predictability in response to treatment. Not everyone gets better easily.

In the real world, psychotherapy is often added to medication management. In STAR*D, there were a number of studies of psychotherapy. Here is one report of adding cognitive therapy to the mix. NIMH summarizes the results as follows:

Switching to or adding cognitive therapy (CT) after a first unsuccessful attempt at treating depression with an antidepressant medication is generally as effective as switching to or adding another medication, but remission may take longer to achieve.
I believe also, that either this study or another study had evidence that showed that the subjects, when given a choice of medication change or psychotherapy, often opt for medication change. There are two reasons for this. First, taking medication is easier and less anxiety-provoking than going once a week for psychotherapy. Second, all of the television ads for drugs give the impression that they are the way to go. Yet several types of psychotherapy, most notably cognitive therapy and interpersonal therapy, have very good track records.

All of this is equally true with the elderly. Miller argues that psychotherapy is particularly important for the elderly:

Every depression is expressed in an interpersonal context and thus its effects in the patient cause ripples that sometimes damage relationships that need to be addressed for potential repair work. The goals of combination treatment in late life are to:
Be able to restore a state of homeostasis or balance by lessening the severity of the depression (and any comorbid anxiety).
Maximize the coping ability of the patient.
Foster a more positive outlook of remaining strengths and opportunities.
Solicit external supports to foster not only a sense of being "backed up" but also a sense of having valued and purposeful integration into a social network.

Working with the elderly is different from other types of psychotherapy, because there is more emphasis on coping with problems in the real world. Therapists often worry that elderly clients will be too rigid to benefit from therapy. However, that rigidity is often outweighed by a strength not possessed by younger clients. Elderly persons have been through a lifetime of problems and usually have a well-developed repertoire of coping skills. The trick in therapy is to identify them and encourage the client to use them again.

So, the answer to the question, medication, psychotherapy, or both? is "It depends." It's frustrating that mental health professionals have not been able to identify who will profit from what kind of treatment. It's still very much a trial-and-error process, despite a significant amount of science in both medicine and psychology. By combining psychotherapy and medication, we can often bring out the best of both treatments. Miller illustrates this by paraphrasing Kay Redfield Jamison (An Unquiet Mind): "Lithium diminishes my depression, but psychotherapy heals."

I'm Having Flashbacks

2008-01-03T09:26:00.001-05:00
I just discovered Ph.D. Comics. The most recent comic is giving me flashbacks to grad school.

Happy New Year and a Return to Blogging

2008-01-01T15:28:00.000-05:00
Once again, I'm back; this time after a 5 month hiatus. I've been away for several reasons. I just finished some remodeling work in my house, which took a lot longer than I thought. My house is almost 100 years old, so there's always something to be done, and it's never as simple as it starts out to be. Then, too, I had to enjoy the summer. But, it's the new year, and it's time get back on the horse. I do enjoy blogging. It just takes so much energy.

The New York Times has an interesting article entitled, "The New Year's Cocktail: Regret with a Dash of Bitters." It's about New Years Day descent into regret about choices not made:
An opportunity, that is, to forestall the traditional morning-after descent into self-examination, that lonely echo chamber of what should and could be.

Ghosts roam around down there, after all, and they are the worst kind — alternate versions of oneself. The one who did not quit graduate school, for instance. The one who made the marriage work. Or stuck with singing, playwriting or painting and made a career of it.

Lost possible selves, some psychologists call them. Others are more blunt: the person you could have been.
This is a lyrical, but a-grammatical passage, which is somewhat surprising for the Times. But I like the metaphor of the ghosts. Looking at those ghosts may make us say, "If only I had done this differently, my life would have been WONDERFUL!!"

Ecch. When I start thinking that way, I always get in contact with my inner H. L. Mencken. Yeah, I could have stuck with singing. And today I could be living in a dump asking myself why I didn't go to grad school.

Life is about choices. Every time we make a choice, we cut off one universe of possibilities and embrace another universe of possibilities. I think of these possibilities as paths, and we walk along the path set by our previous choices. The great joy of life is how those paths take us to unpredictable places. Sometimes the places are enjoyable, sometimes they're not. When we find our path taking us to a place we don't want to be, all we can do is make new choices.

Because of this idea, I've been trying to stop referring to good or bad decisions. A decision puts us on a path which itself is infinite, so it never “turns out.” It simply opens up some choices and closes off others. I can make a decision very carefully, by considering all the options, seeking advice, and carefully selecting a plan of action. It can still put me on a path that takes me to a bad place. Once I see that I'm coming to a bad place all I can do it make new choices. But I will never know what would have happened if I had made a different choice and not taken that path.

Ultimately, our lives are the totality of the choices made and the paths taken. When we take a path, we make it real. The paths not taken exist only in the realm of imagination. So, if you ever find yourself wondering, "Why was I so stupid as to make that choice?" just remember the old line. "It seemed like a good idea at the time."Then go and make more decisions and make some new paths real.

In Memory of Albert Ellis

2007-07-25T13:32:00.000-04:00
The New York Times reported today that Albert Ellis has died. Ellis is the founder of what he originally called "rational therapy," then called "rational-emotive therapy," and most recently called "rational-emotive behavior therapy," or REBT. He was a tireless lecturer and writer. He was also a shameless self-promoter and total character. He was known as the Lenny Bruce of psychotherapy.

Ellis started writing and lecturing in the 1950's and continued his work until his death. This year, he was giving seminars from his bed in a nursing home. He founded an institute, currently called the Albert Ellis Institute in New York. In many ways, he has been at least as influential as Freud.

Ellis's great contribution was the recognition that our feelings do not come from what happens to us. Instead, our feelings stem from what we tell ourselves about what happens to us. For example. Imagine you get a B on an exam. First, imagine telling yourself, "Oh, God, I'm such a fool! I only got a B. I'll never get into a good school. I'll never accomplish anything. My parents will be disappointed in me!" You can easily see how upset you'll get.

In contrast, imagine yourself saying in response to the B, "Oh, boy. Only a B. I was hoping for an A. What did I do wrong? What can I learn from this?" Here, you might feel disappointed, but not crashingly depressed.

Finally, imagine yourself saying, "Boy am I proud of myself! This was really hard. I didn't think I could do this well!" Then, you feel good.

Ellis's point is that the B didn't make you feel anything. Your thoughts about the B--what you say to yourself--affect your mood. So, you can't tell your spouse, "You made me angry!" That's an unrealistic--Ellis would say irrational--belief. Your spouse may have done something you don't like, and you have every right to object to it, but you made yourself angry.

I saw Ellis speak several times over the years. He always said the same things. Sometimes he would change names, or refine previous ideas, but he never deviated from this basic message. His lectures were always the same. First, he would talk about his approach, then he would demonstrate therapy with volunteers from the audience. He always peppered his speeches with obscenities.

The last time I saw him, he was in his late 70's, still going strong. I often tell my clients about this, because he managed to explain his approach in two words.

After explaining how thoughts affect mood, Ellis began talking about how to change what you tell yourself. He said,

"There are two words you can tell yourself that will get you through any situation, no matter how bad it is."

You can imagine, this whole room, overflowing with clinicians. We all thought to ourselves, "Oh, boy, we're going to get some wisdom from the Master!" We all leaned forward, and Ellis said,

"TOUGH SHIT!"

Broke up the joint.

Ellis's whole life was a tribute to those two words. He started his career at the time that psychoanalysis and humanism were the dominant clinical trends. Everyone thought he was crazy, and the criticism was whithering. Ellis didn't care, basically saying, "They don't like what I'm saying, tough shit. I know I'm right." He outlived all his critics and has been revered as the last of the Grand Old Men of psychology. Today, with variations, an awful lot of us are doing therapy his way.

For about the last 25 years, Ellis was somewhat eclipsed by Aaron Beck's "cognitive therapy." Yet, Beck openly admits that he based his approach on Ellis's ideas. Beck was successful because he was more dignified, if less interesting, than Ellis. He made for a better face for psychotherapy. But, I doubt that cognitive therapy would be where it is today, were it not for Ellis and his willingness to be such a character.

If we live well, we touch the world in some way; we usually don't know how. But Ellis died knowing that the things he believed in were now part of clinical psychology's mainstream. That's an incredible legacy.

Psychoanalysis Evolves: Freudian Dissenters

2007-07-04T12:03:00.000-04:00
This is the second post in my series on psychotherapy. I know, I've been gone a long time. My stats show it, too.

When Freud published The Interpretation of Dreams, he became a very controversial figure because of his emphasis on sexuality. He went through a brief period where he worked in isolation, but, by 1902. he began to gather a group of physicians around him. By 1908, the group had grown into the Vienna Psychoanalyic Society. Two early members of the Society eventually split from Freud: Alfred Adler and Carl Jung.

Carl Jung

Jung and Freud were very close and Freud saw Jung as his successor. This relationship soon fell apart, however, as Jung began to diverge from Freud's views. There are many accounts (some of them scandalous) of their final split, which, fortunately, are irrelevant to my goals for this series.

Jung's theory, like Freud's, is extremely complicated. A good summary of his ideas can be found here. Jung became fascinated with symbols, and began to see a cross-cultural pattern in them. He argued that there are "archetypes" among those symbols which relate to common human heritage, not just the individual's experience. Thus, each of us has a set of common symbols within us, which Jung referred to as the collective unconscious. The collective unconscious coexisted with the personal unconscious.

For Jung, neurosis, or mental illness in general, resulted from attempts to cut off elements of both the collective and personal unconscious from the conscious experience of the individual. Humans have an innate need for "self-realization," which involves understanding and integrating all of the material from the collective and personal unconscious. Proceeding with self-realization results in "individuation," the process of becoming a unique and unified individual.

Psychotherapy for Jung was less structured than psychoanalysis. He did not use free-association the same way Freud did. Rather, he relied on the spontaneous discussion of the individual. Like Freud, he analyzed dreams and verbalized symbols. He was less concerned with uncovering trauma and more concerned with tracing the relationships among symbols. He also understood symbols more in terms of common human experience and less in terms of sexuality. Through therapy, individuals become more centered and more comfortable with their own contradictions.

Alfred Adler

An early member of Freud's inner circle, Adler was the first to break with Freud. A good summary of his ideas can be found here and here. Adler anticipated much of modern psychology and psychotherapy. He dispensed with Freud's instinctive psychology and focused instead on the goal-oriented nature of human behavior.

Adler saw individuals first and foremost as social creatures, forming goals and striving to meet them. Where Freud talked about the superego managing our behavior, Adler conceived of the role of values. This is an oversimplification, but essentially Adler saw mental health in terms of (a) having healthy values, which affect what goals we try to achieve, and (b) having both the confidence and the ability to achieve those goals.

This means that analysis was very straightforward. The analyst encourages the patient to overcome feelings of insecurity, develop more rewarding and meaningful relationships, and to pursue healthy life goals. Insight and exploration of the patient's past occur early in the relationship, but later on, there is more emphasis on behavior change.

There were two critical differences between Adler and Freud. First, Adler emphasized the role of empathy in the therapeutic relationship. For Freud, the analyst was supposed to be a blank slate. This encouraged the development of transference. The interpretation of transference was critical for psychoanalysis. In contrast, Adler argued that the analyst should develop an empathic relationship with the patient, stimulating hope and commitment to the process. Second, while Freud encouraged the analyst to be quiet and allow the patient to free associate, Adler encouraged the analyst to engage in Socratic dialogs to help the patient achieve insights.

Conclusions

Jung and Adler are really polar opposites. Adler was much the realist, while Jung was much more mystical. Together, Jung and Adler moved analysis off the couch and put it across the desk. This changed the dynamic between the patient and the analyst, making it possible to create the modern collaborative relationship.

Both Jung and Adler continue to be influential, and there continue to be institutes (e.g., Alfred Adler Institutes and C. G. Jung Institutes) devoted to their ideas. While Jung is better known, it has been Adler whose influence has been most pervasive in modern psychotherapy. He anticipated the more active approaches we use today and was the first analyst to downplay the emphasis on probing the unconscious. We will come back to him briefly when we discuss cognitive-behavior therapy.

A Brief History of Psychotherapy: Freud

2007-05-20T20:16:00.000-04:00
When I originally conceived of this series, I thought it would be a brief set posts. I can already see that I was overly optimistic. There's an awful lot of material here. So, at this point, I'm not sure of how many posts it will take to complete this project.

Freud, Charcot, and Hysteria

Most people believe that psychotherapy began with Freud. Actually, Freud himself (Himself?) began as a student of the French neurologist, Charcot, who was investigating the phenomenon of hysteria. In this disorder, patients, mostly women, would manifest symptoms of physical disorders (such as paralysis or blindness) with no known physical causes. (Space prevents me from dealing with the feminist issues here.)

Charcot discovered that hypnotizing his patients and encouraging them to talk about their symptoms would result in their remission. Freud was very impressed with this and began trying Charcot's technique on his own patients. He began a brief collaboration with Josef Breuer, and in 1895, they published Studies on Hysteria, probably the first book ever published on psychotherapy.

Freud apparently was either not a very good hypnotist or not a very enthusiastic hypnotist and soon abandoned hypnotic induction. He kept everything else in place; the patient would lie down on a couch in a dimly lit room and begin talking about her symptoms. There is an apocryphal story that Freud initially used to question his patients to clarify what they were talking about. On at at least one occasion, the patient said, "Don't interrupt me when I'm talking," and Freud learned to be quiet and listen during free association. This is the form of classical psychoanalytic practice: a period of free association followed by interpretation of the material by the analyst.

Freud's initial work led to the publication of The Interpretation of Dreams in 1899. (The publisher later dated the book for 1900, probably to identify it with modernity.) This book, along with his later book, An Outline of Psychoanalysis, (published in 1940) contain the best material on Freudian psychoanalysis.

Personality and Behavior

Psychoanalytic theory is highly complex and was constantly evolving under Freud; I cannot do it justice here. Nevertheless, to understand why Freud did what he did, you have to understand some part of his theory of personality.

For Freud, personality reflected the interaction of forces inside the psyche. These intrapsychic forces interacted and opposed each other. The healthy psyche was one where the forces balanced each other out and energy was expended in rational behavior. These forces interacted within and between three major structures in the psyche: The id, or unconscious mind; the ego, the conscious, rational part of our minds; and the superego, essentially our conscience, although Freud thought of it as the internalized parent.

The id is driven by instincts to either create or destroy. The basic physiological instinct associated with creativity is, of course, sexual reproduction. Aggression is the basic physiological instinct associated with destruction. Because the id is the only source of energy, it is always the central player in our behavior.

The ego and the superego obtain energy from the id through symbolization. The id is unable to tell the difference between reality and the symbol; that is the job of the ego. Hence, the ego would direct the individual to engage in behaviors symbolically related to these instincts. Anything, from playing a musical instrument, to telling a joke to a friend, to doodling on a piece of paper would accomplish this.

It is the job of the superego to control the impulsive, reckless, and immoral behavior of the id. In the healthy individual, the ego is the negotiator between them; in the unhealthy individual, the ego is the battlefield between them. When the superego is in control, the individual is rigid, compulsive, and intolerant. In this three-way interplay, the symptoms of mental illness emerge.

Treatment

It is important to understand that treatment actually evolved before the theory did. Freud thought that his treatment worked. After being analyzed, symptoms of hysteria seemed to go away. Hence, psychoanalysis is really an explanation for why treatment worked.

Treatment, for Freud, was a matter of balancing intrapsychic forces. For doing this, he had three primary tools: Free association, dream interpretation, and analysis of the transference relationship. Free association gives us the classical image of the patient on The Couch.

Free association. Free association, as described above, provided the primary data for analysis. It was assumed that if the patient was talking about it, it was important. The juxtaposition of different ideas gave a clue about unconscious connections between them. Symbolization was manifested both in free association and in dreams, and proper interpretation was crucial to treatment.

Dream interpretation. Freud regarded dreams as the "royal road to the unconscious." He found that patients often discussed dreams during free association and became convinced that dreams represented unconscious processes. By analyzing the dream symbols, the analyst developed insight into the patient's problems.

Transference. Transference refers to the manner in which the patient responds to the analyst. Does the patient idealize the analyst, or does the patient "forget" about appointments? Freud concluded that the patient "transfers" his or her feelings about the parents onto the analyst. This, of course gives clues about early family relationships that are so critical to the development of the individual. To this end, Freud argued that the analyst should be as bland as possible.

Countertransference is the other side of the coin and refers to the feelings of the analyst toward the patient. While this gives insight into the analyst's state of mind, it also helps the analyst understand how the patient affects other people. If, for example, the analyst feels angry at a patient, it may suggest that the patient is behaving in a hostile manner toward the analyst. That provides much data for the analysis.

Analysis. Using these tools, Freud investigated the unconscious life of the individual. By uncovering unconscious conflicts and developing insight, Freud believed that he could strengthen the ego and redirect the emotional energies in a healthier manner. This always involved understanding the internal symbolic world of the individual, and the symptom was always linked symbolically to the underlying trauma. If, for example, a patient complained of hysterical blindness, Freud assumed it was because they had seen something awful. Hence, it was necessary to uncover the traumatic event the patient had seen, to relieve the symptoms. Generally, for Freud, the traumatic event involved childhood trauma.

By developing insight and uncovering repressed trauma, energies attached to inappropriate objects can be released and appropriately redirected by the ego. Freud used the term, catharsis, to refer to re-experiencing the emotions related to the trauma. Release of the tensions associated was called "abreaction."

Conclusions

For those who know something of Freud, you will note that I have said nothing about his theories of development. I have done that deliberately. I am more interested in focusing on psychotherapy than on personality development or psychopathology. I will only say in passing that Freud was very right to observe that a child is not a small adult. His scheme of development was very wrong.

Freud remains a controversial figure today. We continue to argue about his strengths and weaknesses. (A good discussion of the strengths and weaknesses of classical psychoanalytical theory is contained here.) In relation to psychotherapy, I think it is safe to say, he made several significant errors.

First, Peter Kramer, in his book, Freud: Inventor of the Modern Mind, argues that a great error of Freud was his belief that the symptom is a symbol. For Freud, the symptoms were always related to the underlying psychodynamics of the individual. We know now that is not true. Depressed people show similar symptoms regardless of their underlying dynamics. So, for example, if a person experiences panics when out of the house, Freud would have assumed that the person experienced some trauma outside of the house. The goal of treatment would involve uncovering that trauma and unlocking the emotions associated with it.

Freud's second error was that he didn't understand the role of the situation, and saw behavior as a function of the internal dynamics of the individual. Freud did not recognize that individuals acquire maladaptive behavior through experience. A child growing up in an abusive environment learns to be a perfectionist because it helps reduce the abuse. It's not because of a rigid superego.

Third, Freud did not understand the influence of culture. We know that as culture changes, symptoms of mental illness change. Freud saw a lot of hysterical blindness and paralysis. We see almost none of it today. In fact, I have been in practice for over 30 years, and I have yet to see an individual with hysterical blindness. Similarly, Freud saw the role of women as being biologically, not culturally determined. He would be amazed to see women working along side of men, much less fighting in the military.

Finally, Freud hoped that someday psychoanalysis would be subjected to scientific evaluation. But, psychoanalysis is not a scientific theory, especially as science is practiced over 100 years after The Interpretation of Dreams was written. Psychoanalysis is too complex and it makes too many conflicting predictions. There is also a paucity of systematically collected data. But, that does not mean Freud has nothing to offer us.

As I said previously, Freud was a visionary. His ideas are so ingrained in us today, that we cannot conceive of a world without the idea of unconscious motivation. For me, Freud, beginning with almost nothing, made three significant breakthroughs.

First, through his concept of transference, Freud uncovered the therapeutic relationship. Today, we understand that the relationship between the therapist and the patient is the primary vehicle for change. The therapist and the patient must have a relationship of mutual trust and respect if the patient will explore material that is potentially shameful and anxiety-provoking. The modern view of the therapeutic relationship is broader than Freud's, but there is no doubt that he originated the idea.

Second, Freud recognized that something is going on in people's minds that they are unable to talk about. Most modern therapists do not talk about investigating the unconscious, but they do recognize that there are things going on the person's head that are relevant but difficult to identify and change.

Finally, and most importantly, Freud recognized that speech is a very powerful tool. The term, "talking cure" came from one of Freud's patients, and it is a very apt description. Without Freud, there would be no psychotherapy today.

Coming Soon

Today, it is safe to say that there are few orthodox Freudians left. In fact, early in the twentieth century, contemporaries of Freud began to elaborate and diverge from his thinking. By the 1950's psychoanalysis had evolved significantly from it's roots. My next post will trace that change.

A Series of Posts on Psychotherapy

2007-05-13T09:09:00.000-04:00
I'm going to begin a series of posts on psychotherapy, which are long overdue. When I started blogging, I anticipated writing a lot about the science of psychotherapy, but I haven't followed through with it; I've been having too much fun with other things.

Two events have come together to get me started. First, at Aardvarchaeology (on ScienceBlogs), there was a recent post entitled, Is Psychotherapy Superstition? in which the author, Dr Martin Rundkvist, seemed to be confused about what psychotherapy is. Furthermore, some of the commenters on the blog seemed totally unaware of the evidence for the effectiveness of psychotherapy.

Second, I put off a post on a story in last week's New York Times Magazine by Bruce Stutz, who decided to withdraw himself from Effexor. Stutz initially went on Effexor after becoming depressed during difficult period in his life. He stayed on the drug for several years, and was advised to stay on it the rest of his life. He decided that he didn't want to and weaned himself off, but experienced severe withdrawal symptoms in the process:
Over the next several days they (low doses of Effexor--F.O.) came in handy, especially at night, when I would wake up feeling dizzy, almost seasick, disoriented and in a heavy sweat, the pillow soaked. One night, awake and not eager to go back to lying restlessly in bed, I went online, typed in “Effexor withdrawal” and found bulletin boards full of pained, plaintive and sometimes angry posters who had quit taking their medication and were suffering a broad but surprisingly consistent range of symptoms: dry mouth, muscle twitching, sleeplessness, fatigue, dizziness, stomach cramps, nightmares, blurred vision, tinnitus, anxiety and, weirdest of all, what were referred to as “brain zaps” or “brain shivers.” While there were those who went off with few or no symptoms at all, others reported taking months to feel physically readjusted.
Stutz eventually did wean himself off Effexor, and has not had a recurrence of depression. He puts his finger on the issue:
If my psychiatrist had told me, “I think you can do this without taking any drugs,” would I have done just as well? If I had been told how difficult it would be to get off the drug, would I have so readily started on it? Even the doctors and researchers who most believe in the effectiveness of antidepressants acknowledge that the “chemical balance” paradigm, the magic-bullet paradigm, makes things seem simpler than they actually are. For some, these drugs may be a lifesaving treatment. But for most of us troubled or even temporarily anguished by life’s difficulties, does our long-term reliance on these drugs become more of a convenience than a cure, allowing us to simply keep going in the midst of very difficult circumstances? And once we start taking them, how do we find the wherewithal to stop?
To make a decision between drugs alone, psychotherapy alone, and both combined, patients need to understand what psychotherapy is. It is not a panacea, as it was once advertised. It's not for all people, or even for all depressed people. Prospective clients of a psychotherapist need to understand what they are getting into. So, there are three topics I want to address in this series.

First, I'll talk about what psychotherapy is and is not. To do that, I have talk about the history of psychotherapy and how we got to where we are today. Next, I'll give a brief description of research in psychotherapy, and finally, I'll talk about how therapy and medication work together in treatment.

I hope this will give readers a better idea of what to expect if they seek psychotherapy and a better ability to understand some of the stories about the effectiveness of therapy that emerge in the press. All treatments for physical and mental illnesses involve decision making. The more you understand the options, the better.

The Tyranny of the Shoulds

2007-05-06T19:09:00.000-04:00
I was reading the New York Times, as usual, and stumbled across two articles I knew I should blog about. The first was Bruce Stutz's account of his withdrawal from Effexor, an antidepressant drug. Effexor is a very popular drug, especially among primary care physicians, and it can be very hard to get off. His story is, at points, gruesome. But it speaks for itself, and right now I have nothing to add. I will soon, though, so stay tuned.

The second story is much funnier and more enjoyable. It's an article in the Book Review, entitled, Why Not the Worst? In it, the author, Joe Queenan, writes about his love of bad books and compares himself to others who are obsessed with quality:
Most of us are familiar with people who make a fetish out of quality: They read only good books, they see only good movies, they listen only to good music, they discuss politics only with good people, and they’re not shy about letting you know it. They think this makes them smarter and better than everybody else, but it doesn’t. It makes them mean and overly judgmental and miserly, as if taking 15 minutes to flip through “The Da Vinci Code” is a crime so monstrous, an offense in such flagrant violation of the sacred laws of intellectual time-management, that they will be cast out into the darkness by the Keepers of the Cultural Flame.
Queenan goes on:
Some people would identify a passion for bad books as a guilty pleasure, but I prefer to think of it as a pleasure I do not feel guilty about, even though I probably should. Bad movies, bad hairdos, bad relationships and bad Supreme Court rulings merely make me chuckle. Bad books make me laugh. And if they ever stop writing books with lines like “Being a leader of the Huns is often a lonely job,” I want to stop breathing on the spot.
So, what does this have to do with psychology?

Queenan is attacking what Karen Horney (pronounced HORN-eye), an early neo-analyst, called "the tyranny of the shoulds." In this, Horney anticipated the cognitive-behavioral therapies of Albert Ellis and Aaron Beck.

Horney recognized that we carry around many beliefs about what should or should not be. Some shoulds are about what happen to us. We believe, "I should be successful," or "My spouse should know what I want without my saying so." Unfortunately, that's just not realistic.

We have every reason and right to want things. But, "should-ing" is based on the unrealistic belief that the world must grant us what we want, just because we think we're right. When the world doesn't cooperate with that belief, we get angry or depressed.

Some shoulds address standards for our own behavior. For example, "I should read only good books." These shoulds make us rigid and rob us of our pleasures. Why not enjoy a bad book occasionally? Queenan's observation, "I prefer to think of it as a pleasure I do not feel guilty about," is a wonderful rejection of those shoulds.

When I hear a client bring up their shoulds, it is my job to attack those beliefs and replace them with more flexible beliefs. Some clinicians use Socratic questioning to attack peoples shoulds. For myself, I've found that far too often, Socratic questioning turns into the Possum Lodge Word Game. Instead, I like to hit people between the eyes with a one-liner.

Needless to say, I'm always on the lookout for a good one-liner. Now, I can't wait to say to a client, "Don't think of it as a guilty pleasure, think of it as a pleasure you don't feel guilty about."

Comments are now being moderated

2007-05-04T23:16:00.000-04:00
I've been getting spammed by an idiot pushing drug paraphernalia. So, until he or she gets tired and goes away, I'm moderating comments.

Sorry for the inconvenience.

Virginia Tech School Shootings

2007-04-18T09:38:00.000-04:00
I have been trying to write a post on the awful events at Virginia Tech. Every time I try to talk about the psychological issues involved, I sound horribly intellectualized, so I've left that post for another day.

Instead, I will just express my compassion for the victims and their families. I was in college in Ohio when the Ohio National Guard shot several students at Kent State during a demonstration. So, although it was a long time ago, I can imagine how it feels to students to have their security ripped away from them. I can understand why people living and working at other institutions have been affected. The college campus will never again seem like an idyllic place to them.

As a parent, I can barely imagine the families' grief. Losing a child to violence is a parent's worst nightmare. If it were my children who were shot, I would be experiencing overwhelming rage. If my children hadn't been shot, I don't know if I could let them return to school.
One thought keeps going through my head. I think of Mr. Cho's parents. I cannot imagine the guilt, shame, and grief that they must be feeling. I look for news stories about them, and so far, they are absent, thankfully. When they finally get dragged out in front of the cameras and pontificators, it will be awful.

My heart reaches out to all who have been touched by this awful tragedy. I think of Harold Kushner, in his book, When Bad Things Happen to Good People. In it, he grapples with the randomness of tragedy:

Some people will find the hand of God behind everything that happens. I visit a woman in the hospital whose car was run into by a drunken driver running a red light. Her vehicle was totally demolished, but miraculously she escaped with only two cracked ribs and a few superficial cuts from flying glass. She looks up at me from her hospital bed and says, "Now I know there is a God. If I could come out of that alive and in one piece, it must be because He is looking out for me up there." I smile and keep quiet, running the risk of her thinking that I agree with her (what rabbi would be opposed to belief in God?), because it is not the time or place for a theology seminar. But my mind goes back to a funeral I conducted two weeks earlier, for a young husband and father who died in a similar trunk-driver collision; and I remember another case, a child killed by a hit-and-run driver while roller-skating; and all the newspaper accounts of lives cut short in automobile accidents. The woman before me may believe that she is alive because God wanted her to survive, and I'm not inclined to talk her out of it, but what would she or I say to those of the families? That they are less worthy then she, less valuable in God's sight? That God wanted them to die of that particular time and manner, and did not choose to spare them?

Kushner's ultimate answer to this question is that it is the wrong question. The definition of an imperfect world is that bad things happen to people who don't deserve it. So, the more important question is, "What do we do now that bad things have happened?"

For him and for me, it is humanity's job to help all people heal from these terrible wrongs. We need to give up the blaming and finger-pointing and instead give strength to all the survivors. We do that with kindness and understanding.

Psychological Effects of Daycare: Round 2

2007-04-01T15:41:00.000-04:00
A story in the New York Times dated March 26, 2007, entitled, Poor Behavior Is Linked to Time in Daycare sounded pretty scary, so I looked into it in more detail. This is an issue that worries a lot of parents. They apparently turn to the Internet for information; my previous post on the topic is the fifth ranked entry page on my blog.

The New York Times story was pretty weak, as there were some details either missing or garbled, so I found the article on line. It was recently published in the March/April 2007, issue of Child Development. If you don't subscribe to the journal, it's $29.00 to get access. Seems kinda steep to me. Fortunately, ScienceDaily has a good summary of the article on line.

The study is part of a larger multi-site research project led by the National Institute of Child Health and Human Development (NICHD). The lead author was Jay Belsky, a somewhat controversial researcher who has been raising questions about the effects of childcare for years. I think he's gotten a bad rap. As we put more and more children into child care, we are conducting an experiment on our children and Belsky has been looking at the outcome of that experiment. He's asking questions that need to be answered. The problem is that his results are often complicated and get oversimplified in the press, leading to unnecessary huffing and puffing. These data are a classic example.

The Study

The study analyzed data on 1,364 children, who NICHD had tracked from birth. This is not a representative sample. They had recruited the families through hospital visits shortly after birth and collected data on academic achievement, intellectual, and social development from birth to the present day. This is a longitudinal study, which means the children were repeatedly evaluated on the same instruments, so they have a picture of how the children have changed over several years.

ScienceDaily continues:
During the study, researchers measured the quality, quantity and type of child care the children received from birth until they were 54 months old. Child care was defined as care by anyone other than the child's mother that was regularly scheduled for at least 10 hours per week. This included care by fathers, grandparents and other relatives.
The researchers then evaluated the children's academic achievement, cognitive (intellectual) functioning from kindergarten through fifth grade and social development through sixth grade. Other factors, such as parenting quality and the quality of classroom instruction, were also measured. These other factors were taken into account when examining the association between early child care and children's subsequent development. The study tracked children's experience in child care. It was not designed to determine cause and effect and so could not demonstrate conclusively whether or not a given aspect of the child care experience had a particular effect.
Results

The results of the study were pretty complex, but the two big findings that stood out:

An evaluation of the children in fifth grade showed that the children who had higher quality child care continued to show better vocabulary scores, a correlation that was seen previously from kindergarten to third grade. Vocabulary was assessed using the Picture Vocabulary subtest of the Woodcock-Johnson Psycho-Educational Battery -- Revised, which measures children's ability to name objects depicted in a series of pictures.
The researchers found that the correlation between high quality care and better vocabulary scores continued regardless of the amount of time the child had spent in child care or the type of care. The researchers wrote that this finding was consistent with other evidence indicating that children with greater early exposure to adult language were themselves more likely to score higher on measures of language development. However, child care quality was not associated with improved reading skills after 54 months of age.
The researchers also found that, as in the earlier grades, children with more experience in child care centers continued to show, through sixth grade, a greater frequency of what the researchers termed teacher-reported externalizing problem behavior. These behaviors were listed on The Child Behavior Checklist Teacher Report Form, which consisted of 100 problem behaviors.

So, this data indicates that quality daycare is associated with better language scores and more disruptive behavior. But, these results are very equivocal. First, the differences in language scores disappears after age 4 1/2. That can't be too important in the development of adult language.

Second, the relationship between disruptive behavior and time spent in daycare is very small. As they said in ScienceDaily:

The researchers emphasized that the children's behavior was within the normal range and were not considered clinically disordered.
It would not be possible to go into a classroom and with no additional information, pick out which children had been in center care, Dr. Belsky explained.

Significance versus Importance

So, what happened here? Very simply, there is a difference between statistical significance and importance. When we assess statistical significance, we estimate the likelihood that (in this case) a relationship is due to random chance. If the odds that the relationship is due to chance is less than 5%, we say that the relationship is "statistically significant."

One major factor affecting statistical significance is sample size. Smaller samples are more likely to have random errors affecting the results, so it takes stronger relationships to reach statistical significance. Large samples are less affected by random errors (they tend to cancel each other out), so weak relationships can reach statistical significance. In the NICHD study, they assessed 1,364 children. That's a very big sample. And they came up with very weak relationships. The relationships are not important.

Children in daycare might be slightly more verbal, but being in daycare won't make them grow up to be great orators. Children in daycare might be slightly more aggressive, but spending more time in daycare won't make them grow up to be criminals.

First Birthday

2007-03-26T09:00:00.000-04:00
March 26 is the first anniversary of Just Noticeable Differences. I was shocked to see that the year went so fast. Now that I'm approaching 60, time just flies by.

It has been an interesting year. Blogging has been more difficult than I thought. I had forgotten (or repressed) the experience of writer's block from when I was writing my dissertation. Fortunately, unlike my dissertation, I can get up and leave the computer until my brain reconnects.

Blogging has been very rewarding; it's helped me met some interesting people. The attention I've gotten from readers has been gratifying and a bit surprising. One reason I had named myself Free Operant was because I wasn't sure I was going to get any readers. As a result, I thought, most of what I was writing would be free operants. I'm happy to find out that some people have indeed been reading what I write. Thank you all.

One interesting thing I've found in this year. Blogging anonymously has its own set of limitations, some positive and some negative. On the positive side, I realized it isn't fair for me to attack people from behind a shield of anonymity. I've tried to eliminate snarkiness when responding to people who write under their own name. I may disagree with them, but I should do it respectfully. Their reputation is out there and mine isn't. I think that limitation has made me a better writer. It's easier to be snarky than to be respectful and still disagree.

On the negative side, I also decided that I would create a wall between my real person and Free Operant. Free Operant will never comment on what I do under my real name, and I will never comment on Free Operant under my real name. This is proving frustrating because I am working on another project under my real name that I can't reference.

Finally, even with my anonymity, I would love to discuss events that have happened in therapy, but I can't. A recent article addressed that particular pitfall for medical doctors who blog. I think confidentiality is too critical to come even close to breaching it. Before I ever wrote my first post, I decided to put up a "fence around the law," to use a Talmudic phrase, and never write about anything that ever happened in therapy. There was one point where I was going to post a comment on another blog about an event occurring 30 years ago in therapy. I didn't. It killed me because it was hysterically funny, but I didn't post it.

Overall, it's been a good year. I look forward to many more.

A Passover Story

2007-03-17T21:57:00.000-04:00

We are coming up on Passover, which is a joyous time of year. I thought it would be fun to break away from the serious stuff and post this story, which I wrote last year.

* * *

Passover is a family holiday, where, over a sumptuous meal, we read the story of the exodus from Egypt. It is a very happy time and most Jews have very good memories of family seders.

The text of the story is contained in a book called the Haggadah. Along with the text, the Haggadah also contains commentaries and prayers. It used to be, the only Haggadah you could find was distributed by Maxwell House Coffee. It contained the traditional Hebrew text, along side of a translation written in King James English. Today, there are many different versions available, written with new text and translation into modern English.

The modern Haggadahs written by non-orthodox movements have eliminated a small section from the traditional text. It contains an interplay between three Rabbis, Rabbi Akiva, Rabbi Eleazar, and Rabbi Yose (pronounced, “Yo-say”), in which they recount the number of plagues visited on the Egyptians.

In Exodus we are told there were ten plagues, but through Talmudic logic and deduction, Rabbi Yose concluded there were fifty plagues visited on the Egyptians at the Red Sea. Rabbi Eleazar deduced there were forty plagues visited on the Egyptians in Egypt, and two hundred plagues visited on the Egyptians at the Red Sea. Rabbi Akiva deduced that in Egypt there were fifty plagues, and at the Red Sea there were two hundred and fifty plagues.

For years, I read this as Talmudic pilpul (hairsplitting), and was not sorry to see it go in our current Haggadah. However, I've come to realize that the Haggadah doesn't tell the full story, and I think there's an important message in this commentary.

In the Jewish tradition of the Midrash, I've taken liberties and fleshed out the story. I've interspersed the traditional text in the story below, signified by boldface. The entire text from the traditional Hagaddah is there. But first, we start with some background.

Background

Rabbi Akiva was the dominant thinker of his day. He was not only a great Rabbi, but he was also a leader in the resistance against the Romans. He was later martyred by them in a particularly gruesome manner. So, Rabbi Akiva was not your typical locked-in-the-Yeshiva Rabbi. He was a very smart and very tough guy. Rabbi Eleazar was a contemporary of Akiva's. Not as brilliant, but no slouch, either. Rabbi Yose was one of Rabbi Akiva's students, conceivably one of his best.

In those days, there were no Haggadahs and the recounting of the Exodus was spontaneous. Everybody did it differently. Being invited to a seder with Rabbi Akiva would have been a great honor. The learned, the wealthy, and the powerful would all have been there. His seder would have been a great event, with everyone hanging on Akiva's words as he told the story of the Exodus in his own way.

The Scene

Rabbi Yose was thrilled to be invited to Akiva's seder, and wanted to impress him with his intellect. He spent weeks thinking about the Exodus, studying the Torah, trying to find something there to impress Akiva. On the night of the seder, he was ready.

There were many people present at Akiva's seder. The table was set, and the master expounded on the Exodus with incredible brilliance. Rabbi Yose was in awe of him and almost forgot what he prepared.

It is traditional at the seder to drink four cups of wine, which always adds to the merriment. Akiva seemed bent on blurring the distinction between a cup and a barrel. As the seder wore on, Akiva began to nod off. There was a lull, and Yose realized that this was the best chance he was going to have. He hoped he could wake up Akiva by speaking loudly. Raising his voice, he asked,

“How can we say that the Egyptians were smitten with ten plagues in Egypt, and in the Red Sea, fifty plagues?” The room was silent. He hoped Akiva was listening. He continued,

“Of Egypt, it is said the magicians told Pharaoh, 'This is the finger of God.' But of the sea, it is said, 'And Israel saw the mighty hand with which God smote the Egyptians, and believed in God and believed in Moses, God's servant.' If one finger smote the Egyptians with ten plagues in Egypt, it may be deduced that in the Red Sea they were smitten with fifty plagues.”

The others at the seder were awestruck. They applauded and cheered. They congratulated Rabbi Yose for his insight.

Except for Rabbi Akiva, who was snoring quietly.

Except for Rabbi Eleazar, who was thinking, “Pretty clever, Junior, but not clever enough. Time to put you in your place.” Rabbi Eleazar thought for a moment more. Then he said,

“How can we say that every plague, which The Most Holy, blessed be the One, brought upon the Egyptians actually consisted of four different plagues? Because it is said God was angry at the Egyptians, sending them wrath, indignation, trouble, and a band of evil angels. Wrath is one; indignation is two, trouble is three, and a band of evil angels is four. Hence, we can deduce that while in Egypt they were smitten with forty plagues, and in the Red Sea, two hundred plagues.”

The onlookers at the seder applauded more. They knew they were watching a rabbinical smackdown in progress and wanted to hear how Rabbi Yose would respond. Unfortunately, Rabbi Yose's mind had gone blank and he was thinking that discretion was the better part of valor. He was about to concede gracefully, happy that Rabbi Akiva was asleep. Then came a snuffle and a snort from the head of the table.

Rabbi Akiva opened his eyes and said, “How can we say that each plague which The Most Holy, blessed be the One, brought upon the Egyptians in Egypt consisted of five plagues? Because, it is said, “God sent against the Egyptians the fierceness of God's anger, wrath, indignation, trouble, and a band of evil angels. The fierceness of God's anger is one, wrath is two, indignation is three, trouble is four, and a band of evil angels is five. Hence, we deduce that while in Egypt, the Egyptians were smitten with fifty plagues, and in the Red Sea, two hundred fifty plagues.

All of the onlookers exploded into cheers and applause. Rabbi Eleazar and Rabbi Yose looked at each other, shrugged their shoulders, raised their glasses to Rabbi Akiva, and both took a long drink of wine. Rabbi Akiva took another drink of wine and slowly slid under the table.

The Moral

The Haggadah says that all who recount the story of the Exodus are worthy of praise. This story teaches that no recounting is complete without joy, humor, and some friendly competition.

Father's Age and Serious Mental Illness

2007-03-03T16:51:00.000-05:00
I have recently been corresponding with a reader concerning paternal age and schizophrenia. Schizophrenia is a serious mental illness where the individual suffers from delusions and hallucinations. Thought processes are often disturbed. (It is not a "split personality.") Schizophrenia is widely considered to be a neurobiological disorder, caused by a combination of genetics, the prenatal environment, and environmental stressors.

Surprisingly, the New York Times, which is becoming my favorite psychological journal, also devoted an article to the issue, entitled, It Seems the Fertility Clock Ticks for Men, Too. The article summarizes research on the relationship between the father's age and the risk of birth defects:
Geneticists have been aware for decades that the risk of certain rare birth defects increases with the father’s age. One of the most studied of these conditions is a form of dwarfism called achondroplasia, but the list also includes neurofibromatosis, the connective-tissues disorder Marfan syndrome, skull and facial abnormalities like Apert syndrome, and many other diseases and abnormalities.

“We have counseled for quite a long time that as paternal age increases, there is an increased frequency in new mutations,” said Dr. Joe Leigh Simpson, president-elect of the American College of Medical Genetics.
Both autism and schizophrenia have been tied to paternal age, dating back to research published in 2001. In an interview with Medscape, Dr. Dolores Malaspina described her research, also cited in the New Y0rk Times article. (Also check here, here, and here.) Malaspina and her colleagues performed several large-scale studies of demographic data collected in Israel both through the public health system and the Israeli Army. She stated:
We found that paternal age explained over a quarter of the risk for schizophrenia in the population. At the time, people were skeptical. But the findings have been replicated many times now, and not a single study has failed to find this strong relationship between father's age and the risk for schizophrenia. And at this point, other explanations for the relationship have been ruled out, including social factors in the family, prenatal care, and parental psychiatric ailments. There simply seems to be a relationship between paternal age and schizophrenia risk.
Malaspina described the proposed mechanism for this risk:
When Penrose found that paternal age predicted new human genetic diseases, he proposed the Copy Error Theory. He said that each time the spermatozoa are copied there's an opportunity for a new mutation. Sperm cells divide every 16 days after puberty, so the DNA in the sperm of a 20-year-old father has been copied 100 times, but sperm DNA from a 50-year-old father has been copied more than 800 times.
Think of sperm replication as a copy machine. Each time the a copier makes a copy, slight imperfections are created. If you copy the original each time, you never notice a change. But, if you make a copy of a copy, of a copy, of a copy, ad nauseum, you get the familiar spots, streaks, and fading. Human sperm is created from copies of previous generations of sperm, not from copies of an original template in the individual. The DNA in the sperm of a 20 year old has been copied 100 times, while the sperm DNA from a 50 year old has been copied more than 800 times.

Evolutionarily, this is advantageous because it provides for more variation in the offspring. But, with increased variation, comes the risk of negative, as well as positive, traits being transmitted. These include mental retardation and mental illnesses, notably schizophrenia and autism.

The Times cites critics of this research who argue the truism that correlation does not prove causality. That argument is certainly true, but there is more to the research than just correlation:

First, it is also a truism that, to show a cause and effect relationship, the cause must precede the effect. In the case of paternal age that is certainly the case. Paternal age obviously precedes conception.

Second, other explanations must be ruled out. Malaspina and her colleagues controlled for a number of environmental variables, including an adverse fetal environment, maternal age, and psychosocial stressors. Of course, we can never rule out all possible explanations, so we can only rely on a preponderance of evidence. But overall, the evidence favors paternal age.

Third, to argue causality, there must be a plausible mechanism moving from cause to effect. Copy error theory is certainly plausible. It is consistent with known biological processes.

Finally, to argue for causality, there has to be a convergence of data which is consistent with the explanation. Malaspina presents the following data:
The risk of schizophrenia rises with age, from .007% for fathers under 25; to 1% for fathers 30 -35, and 2-3 % for fathers 50 and older;
The risk factors are consistent across world cultures;
It's consistent with the data on other genetic diseases, as I mentioned above; and
Inbred mice show increasing behavioral disturbances with increasing paternal age.
All of this said, it is important to note that increased paternal age increases risk of schizophrenia, autism, and other genetic diseases, but there are other causes as well. Advanced paternal age is neither necessary nor sufficient for the development of schizophrenia. It is a significant risk factor, and one that can be avoided.

Malaspina argues against warning older men away from having children:
I would personally not discourage anyone from having a child at any age. People weigh their own risks. For the offspring of older fathers, the risk of schizophrenia is about 3%. That means that 97% of the offspring do not have schizophrenia. Other cognitive diseases linked to paternal age include mental retardation of unknown etiology and Alzheimer's disease, and there is a strong relationship between paternal age and autism.
I'm not sure I would completely agree with her. Given this data, I would urge an older man to think twice about parenthood, as I would urge an older woman to think twice. Having a family member with schizophrenia, autism, mental retardation, or other disorder can be a terrible burden for both parents and siblings.

According to one study, about a third of patients with schizophrenia make a full recovery. About one third make a partial recovery, where medication works effectively to manage their symptoms. The remaining one third remain very seriously ill. So, the risks of having an impaired child are small, but the cost can be tremendous, and should not be taken lightly.

Flying Low with NASA

2007-02-09T09:16:00.000-05:00
The bizarre story of NASA astronaut Captain Lisa Nowak has everyone talking. It's raised some predictable and reasonable questions about psychological assessment of astronauts. In a storm of comments at a New York Times blog, The Lede, several commenters correctly observed that this incident is the first incident, and that's a pretty good record. (Of course, that's assuming that it is the first incident. Others may have been covered up.) After an incident like this, however, we should still ask if the assessments are good enough.

I did a search for astronaut selection, and I couldn't find a current list of psychological tests NASA uses. Santy (1994) has an intriguing history (available on Questia), but the book is 12 years old, and given publication lag, the information is even older. In a Google search, I found a recent reference to the Astronaut Personal Characteristics Inventory (ASTROPCI), but little other information. The primary tests they use are predictable, including IQ tests, tests of perceptual-motor functioning, personality inventories, and projectives. It appears that NASA is maintaining an active program of research on personality assessment in astronauts. Nevertheless, several news stories indicate that NASA only assesses astronaut candidates once and never repeats the assessment.

However, here is an intriguing quote from Santy:
The Working Group's position was that personality assessment is underutilized as a resource in astronaut selection, but the empirical record in aviation psychological research of using personality traits as predictors of performance is appalling. This dismal record extends back to World War I and the selection of opponents for the Red Baron. (p. 108-109)

In other parts of the book, Santy correctly points out that psychological assessment is often directed toward identifying psychopathology, but psychopathology isn't a good predictor of success on a job. (Yes, I know there are a host of Dilbert-type jokes here.) This is especially true where the occupation is one in which there are only a small number of people who are employed in the field.

Assessment of personality traits is another way to predict success on various jobs. For example, according to Santy, the 16PF, a personality inventory measuring 16 different personality traits, has been used by NASA in astronaut selection. Logically, different jobs require different traits, so assessing for the right combination of traits would make for a good astronaut right?

No. Personality traits do correlate with behavior, but the correlations tend to be somewhat low. The 16pf is a useful instrument--I've used it myself--but by itself, it's inadequate. No personality inventory is adequate by itself. Generally, we compensate for this weakness by using multiple tests and multiple types of assessment.

That's what NASA does. Each test has a certain likelihood of miscategorization. By using multiple tests, the likelihood of miscategorization declines. NASA takes it farther by also using different types of instruments: Psychiatric interviews are included, as are samples of behavior. Behavioral sampling is done by putting candidates into trainers and assessing their performance under roleplay conditions.

Although NASA doesn't do formal, repeat assessments, there is certainly ongoing monitoring of astronauts. It's the same monitoring that goes on at every job. Both peers and superiors are looking at each astronaut's functioning in training and in everyday performance. I can't prove it, but I suspect that such performance evaluations have washed out people who psychological testing has missed. This brings us back to Captain Nowak.

Why didn't she wash out? From all the reports I've seen, Captain Nowak was a competent astronaut. How could she melt down over a marital separation and a perceived love triangle outside her marriage?

The answer lies in an old argument in psychology: Is behavior controlled by person or situation variables? On the one hand, personality theorists argue that internal variables, such as personality traits, conflicts, and dynamics, control behavior. Behaviorists, on the other hand, argued that the external variables, such as the environment and behavioral consequences, control behavior.

For example, what controls the tendency to cheat on tests? Is it a person's honesty (a trait), or is it the opportunity to cheat (the environment)? The resolution to the argument was predictable. Both person and situation variables are needed together to predict behavior. In many cases, the situation exerts more control than the person. To return to the above example, as the risk of getting caught for cheating drops, the number of students who cheat rises. But cheating never reaches 100%, because honesty is important, too.

The Milgram obedience experiment is another example of the power of the situation, as is the Zimbardo prison experiment. The situation has powerful control over the individual. Change the situation and you change individual behavior.

So, Captain Nowak was able to function in the setting of the astronaut corps. She could work in an environment where death was always looming. She just couldn't deal with the environment where rejection had occurred. You're not going to get rejection on the space shuttle. For reasons that I am not privy to, abandonment and rejection were more threatening than death to her. I don't think any amount of psychological testing would have prevented this awful situation.

References

Santy, P. A. (1994). Choosing the Right Stuff: The Psychological Selection of Astronauts and Cosmonauts. Praeger.

A Sports Rant

2007-02-04T15:06:00.000-05:00
Today, being Superbowl Sunday, is a good day for a sports rant. Not too long ago, I was a pretty avid sports fan. Over time, I became disillusioned. Professional sports cause too much damage.

I first learned about the damage athletics can cause when I evaluated a soccer player who had been deafened while playing indoor soccer. (I can talk about this because his evaluation is a matter of public record.) The poor guy had no job skills at all. He'd spent his life preparing for major league sport (he was British) and he never made it. What was he going to do now that he's completely deaf?

I also learned while working on this case, that most professional soccer players suffer headaches and memory loss consistent with head injuries. They use their heads as a tool, but wear no head protection. At least football players wear helmets. Which do a fat lot of good.

Recently, there have been a series of articles about the health of retired football players. Many of them are dealing with depression, memory loss, sleep apnea, and arthritis. According to a recent New York Times article, head injuries, caused by repeated concussions, can lead to depression and suicide:
Since the former National Football League player Andre Waters killed himself in November, an explanation for his suicide has remained a mystery. But after examining remains of Mr. Waters's brain, a neuropathologist in Pittsburgh is claiming that Mr. Waters had sustained brain damage from playing football and he says that led to his depression and ultimate death.

The neuropathologist, Dr. Bennet Omalu of the University of Pittsburgh, a leading expert in forensic pathology, determined that Mr. Waters's brain tissue had degenerated into that of an 85-year-old man with similar characteristics as those of early-stage Alzheimer's victims. Dr. Omalu said he believed that the damage was either caused or drastically expedited by successive concussions Mr. Waters, 44, had sustained playing football.
Waters case is similar to that of Mike Webster, who played for the Pittsburgh Steelers. Here is part of his obituary from the Sports E-Cyclopedia:
Mike Webster's durability and toughness made him a 4-time Super Bowl champion and one of the NFL's best linemen ever. However, those very qualities also might have led to a brain injury that sent him spiraling into drug use and homelessness. The bare-armed strongman nicknamed "Iron Mike'' died September 24th he was only 50. He was remembered as a great center whose sturdiness personified the Pittsburgh Steelers' championship teams and whose off-field health and drug problems saddened them.

The Steelers initially said Webster died of a heart attack but later declined to comment. Webster was diagnosed with brain damage in 1999, an injury caused by all the years of taking shots to the head. "He was one of the main reasons why we won four Super Bowls,'' Hall of Fame running back Franco Harris said. "Unfortunately, he had some turmoil and misfortune after his football career. He is now at peace.''
Notice that the Steelers initially lied about Webster's illness. I guess we wouldn't want young children asking if sports are a bad idea for them. They should, but we spend too much time telling them how wonderful athletics are.

As bad as professional athletics are for adults, what is happening to young children is even worse. The Times also has a story on a high school football player, a friend of Joseph Addai (who will play in the Superbowl today), who was paralysed in a high school game.

Less clear is the social toll that professional athletics take on us, but I still concerned about it. The American love affair with professional sports has corrupted our values. In school, athletes are often revered. Why? Athletics are entertainment and nothing more. what's so important about them? Shouldn't we teach our children to revere scholars instead?

Nah, I didn't think so.

Children grow up thinking that athletic abilities make them special. They see how much the high school quarterback is revered. Some become so obsessed with it, that they give up their childhood, practicing and playing every chance they get. As they rise up in the ranks of school and professional athletics, their sense of entitlement grows, fed by coaches who use it to motivate them. This is why so many athletes have been arrested for drug abuse and violent crime. They're taught that their athletic skills make them exempt from social rules.

Today, to be "the best" means more than practicing a lot. It means playing when hurt. This is why Andre Waters and Mike Webster suffered brain damage. It also means taking performance-enhancing drugs, and we all know what's being said about Barry Bonds and Mark McGwire. Here is a good resource on the effects of steroid abuse. They are far from trivial.

This attitude has leaked down from the professional ranks, to the college ranks, to the high school ranks, and even lower. I've seen it at every level, including an 11 year old boy. Our love of sports is corrosive and it needs to stop. But, it won't until fans turn away.

Sometimes, the fans sorta get it, but then they back away. A few years ago, the Pittsburgh Steelers and the Pittsburgh Pirates decided they both needed new stadiums. For a while, the fans put up a fuss, but the opposition was all talk and both teams got what they wanted. They spent millions of dollars on PNC Park and Heinz Field. In the meantime, the city of Pittsburgh is fading away. It's downtown is empty. The surge in home prices of the last few years never hit Pittsburgh; there's no reason to live there. That money could have been much better spent on other things.

So, I've lost interest in sports. I'll watch the Superbowl tonight, so I don't sound like a weirdo tomorrow, but I really don't care who wins. I know a lot of people will lose.

More on Decision Making

2007-01-17T09:36:00.000-05:00
I have been plowing through a monograph on adolescent decision-making by Valerie Reyna and Frank Farley, and I found a discussion related to my previous post on decision-making. In the article, they discuss the normative analysis of decision-making:
More formally, the normative analysis of a choice identifies the options in the decision makers’ best interests, given their goals and the information available to them, all integrated by the application of a rational decision rule. Customarily, that is an expected utility rule, which multiplies the utility (or attractiveness) of each outcome by the probability of its being obtained for each option. In these terms, rationality is a matter of consistency with a set of rules, such as transitivity (e.g., individuals who prefer A to B and B to C should also prefer A to C), because following such rules can be shown to result in reaching the decision makers’ goals (i.e., maximizing the attractiveness, to that decision maker, of the chosen option; von Neumann & Morgenstern, 1944; Yates, 1990). Whether people actually adhere to such rules or pursue their own best interests is a detail left to descriptive research as opposed to normative analysis.
(p. 9)
A normative analysis of decision making recognizes that a "good decision" is one that is well-made. The decision-maker considers the alternatives and estimates the probability of achieving different outcomes. The decision-maker then selects the outcome by weighting the attractiveness of the outcome and the probability of achieving the outcome.

Reyna and Farley go on to say:
Normative analyses also recognize that people may rationally pursue goals that others dislike (e.g., adolescents who care more about good times and social approval than adults think is appropriate). Normative analyses recognize that people may make choices with unhappy outcomes because no better options were feasible (e.g., when dealing with bullying or sexual coercion). Normative analyses recognize that bad outcomes may follow good decisions, when chance intervenes, just as good luck may reward poor choices. Indeed, there is a term in decision analysis, outcome bias, for confusing the quality of decision processes and the consequences of decisions (Ritov & Baron, 1995). (p. 10).
This is exactly the point I was making when I described how decisions put us on unpredictable paths. The quality of our decision-making processes affects the likelihood of pleasant consequences, but it cannot guarantee it. Outcome bias confuses the quality of the decision with the path on which the decision takes us.

Outcome bias is so attractive because it is comforting. If I make the "right" decisions, my life will be perfect. If I'm unhappy with where my decisions are taking me, it's because I made the "wrong" decision. It is possible for me to predict the future and make only good things happen to me.

Giving up these unrealistic beliefs and accepting the true nature of decision-making is anxiety-provoking:
It is anxiety-provoking to believe that you can make decisions well, but have them take you to bad places.
It is anxiety-provoking to believe that you can be in a situation where there are no "good" choices; only least-worst choices.
So, we strike a bargain with ourselves. We would rather feel the guilt and regret of having made "bad choices," than to accept that sometimes--no matter how good our decisions are--bad things will happen to us.

Some people embrace this belief through a toxic spirituality, which I've discussed before: If I am a good person, God will keep bad things away from me. If bad things happen to me, it must be because God is angry at me. This thinking can be almost magical: If I'm good to my family, God will reward me at work.

So, these beliefs give us an illusion of control over our lives and fend off the anxiety that the unpredictability of life engenders. Ultimately, to live happily, we must give up these illusions. We have to recognize:
If we make decisions carefully, we have an improved likelihood of taking an enjoyable path, but nothing is guaranteed.
If our decisions take us down an unpleasant path, it is always possible that, around the next bend, better things will happen.
If we are unhappy with the path we are on and are convinced that it won't improve, we can make more decisions and take new paths.
It is rare that a well-made decision will take us down a catastrophic path. It can happen, as in the person who decides to stay late at work and is then hit by a drunk driver on the way home. The probability of such an event is so low that it is not worth worrying about.
And finally, the unpredictability of life is not only threatening, it is also exciting. As I look back on my life, my favorite memories are of those decisions that set me on unpredictable paths. So, instead of embracing outcome bias, I embrace the adventure of life.

References

Reyna, V. F., & Farley, F. (2006). Risk and rationality in adolescent decision making. Implications for theory, practice, and public policy. Psychological Science in the Public Interest, 7(1) (monograph).

Ritov, I., & Baron, J. (1995). Outcome knowledge, regret, and omission bias. Organizational Behavior and Human Decision Processes, 64, 119-127.

von Neumann, J., & Morgensern, O. (1944). Theory of games and economic behavior. Princeton, NJ: Princeton University Press.

Yates, J. F. (1990). Judgment and decision making. Old Tappan, NJ: Prentice Hall.

Ford, Nixon, and the Decisions We Make

2006-12-31T00:04:00.000-05:00

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

2006-12-25T16:54:00.000-05:00
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

2006-12-13T15:36:00.000-05:00

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

2006-11-24T10:01:00.000-05:00
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

2006-11-20T20:53:00.000-05:00
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

2006-11-07T15:43:00.000-05:00

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?

2006-10-28T11:31:00.000-04:00
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

2006-10-27T12:58:00.000-04:00
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

2006-10-24T13:33:00.000-04:00
A new look to the blog. It's called having too much free time.

Internet Addction or Compulsive Behavior?

2006-10-19T15:34:00.000-04:00
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

2006-10-10T12:40:00.000-04:00
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

2006-10-08T11:39:00.000-04:00
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

2006-09-12T21:44:00.000-04:00
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

2006-09-06T08:09:00.000-04:00
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

2006-09-03T13:07:00.000-04:00
It worked!!!
(I think...)

Here we go....

2006-09-03T11:18:00.000-04:00
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

2006-08-26T00:02:00.000-04:00
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

2006-08-21T20:36:00.000-04:00
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

2006-07-30T11:56:00.000-04:00

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

2006-07-10T20:18:00.000-04:00
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.

2006-07-03T13:37:00.000-04:00

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

2006-06-28T10:27:00.000-04:00
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?

2006-06-23T14:36:00.000-04:00
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

2006-06-14T15:39:00.000-04:00
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?

2006-06-12T12:54:00.000-04:00
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

2006-06-04T12:09:00.000-04:00

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

2006-05-29T20:40:00.000-04:00
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

2006-05-16T18:07:00.000-04:00
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?

2006-05-14T11:23:00.000-04:00
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

2006-05-11T23:11:00.002-04:00
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

2006-05-10T23:56:00.000-04:00

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.

Freud and Psychotherapy

2006-04-28T09:57:00.000-04:00
A collection of Sigmund Freud's drawings is scheduled for exhibition at the New York Academy of Medicine, according to a story in the New York Times. The drawings reflect Freud's progression from a neuroanatomist to psychoanalyst. As is obligatory in articles about psychoanalysis, the comment is made, "Freud's methods have fallen from favor in recent decades, but science historians say that his investigation of the unconscious more than a century ago stands as a revolutionary achievement that still informs many therapists' understanding of memory, trauma and behavior."

When I was in graduate school, the conventional wisdom was that Freud's greatest contribution was his concept of transference. In traditional psychoanalytic thought, transference refers to a client's tendency to think of his or her analyst as a parent. The client's behavior toward the analyst was then used as evidence of early relationships and interpreted back to the client.

Today, the term, transference, is out of style. Nevertheless, a good clinician uses behavior in the office as the primary data for treatment. How a client responds to me tells me much about how the client behaves outside of therapy. For example, I usually teach angry clients relaxation exercises, so they can calm themselves when angry. If a client tells me that relaxation exercises seem silly to him, it tells me a lot about how he behaves outside of the session. He may behave judgmentally toward his bosses, coworkers, or family members. Then, I can show him how he angers himself, by saying, "This is silly. I shouldn't have to do this." From there, it's a simple step to restructuring the thoughts by substituting, "It can't hurt to try it and see if it helps."

I certainly don't think of myself as a psychoanalyst, although I respect Freud's genius in uncovering the healing nature of a relationship. Freud did something else, which therapists should never forget. He let his patients teach him about healing.

Psychotherapy for Compulsive Gambling

2006-04-24T16:54:00.001-04:00
Slot machines are coming to Pennsylvania. Like most psychologists who don't work near a casino, I don't see many gamblers. When the slot machine law was initially enacted, I took some continuing education credits to brush up. It taught me how little we really know about gambling.

Mostly, psychologists see gamblers when their luck has run out and their lives are in a shambles. We'll be seeing more of those people as casinos become more common. I just reviewed an on-line book on gambling , [Sorry, this link is dead--F. O. 8/27/2009] dated 1999. It's a little old, but not much has changed since it's publication. It's also a little thin on treatment, but it does have some good data. For those that are into diagnostics, they have a copy of the diagnostic criteria for pathological gambling.

The current issue of the APA Monitor has an article entitled, Gamble at Your Own Risk , which discusses some research on controlling compulsive gambling. The article reports on two studies. In the first, they found that even people well-versed in the probabilities of gambling, will still do it. In one study, students in an introductory statistics class got intensive education in the probabilities of winning at gambling. They still gambled at the same rate as students in a control group.

In the second study, a casino was set up, using a computerized roulette game. Warnings, such as, "If you bet more to make up your losses, you're likely to lose more money" and "If you continue to gamble, you'll eventually lose money," were flashed on the screen. Not surprisingly, students receiving the warnings did gamble less money. But come on, do you think you'll ever see warnings in a casino?

Generally, treatment for pathological gambling follows the addictions model. The goal is not to "recover," but instead to stay in recovery for the rest of one's life. To assist in this process, the clinician must address at least four areas:

1. The negative effects of gambling on the client. The goal is to help the client see that gambling is the cause of all their major problems. Once they are convinced that not gambling will improve their life, they can be engaged in therapy. I always begin by taking a history from my clients. For problems like gambling, the client may find it very traumatic to recount their gambling behavior. Having the client write an autobiography, linking major events in their life to gambling may be a very emotional experience, too.

2. Education about pathological gambling. There are two issues here: First, gamblers need to understand gambling itself, and see that the odds are generally stacked against them. Their unrealistic beliefs about gambling, such as the belief that they can make up for their losses, need to be challenged.

Second, they need to understand their own addictive behavior. For me, the best explanation of gambling comes from basic learning theory. People do what they are reinforced (rewarded) for. There are two rewards for gambling. First, there is a "high" to gambling; a thrill that people report when they are about to pull the lever, lay their money on the table, or watch the outcome of a game or race. That high is very rewarding for the gambler. Second, the behavior is intermittently reinforced. That is, they are rewarded by winning just often enough to keep people playing in the face of their losses. Combining the immediate reinforcement of the high with the intermittent reinforcement of winning makes the gambling behavior very resistant to treatment.

3. Repairing the damage. Pathological gambling does tremendous damage to people's lives. The client needs a great deal of supportive therapy to deal with the financial or legal fallout from the gambling. It's not unusual for a person to have repeatedly run up tens of thousands of dollars in debts, leaving the family struggling to get by. Often, the gambler has embezzled money from their employer, also and may be up on charges as well. In addition to individual therapy, family or marital therapy is necessary to heal the anger that loved ones feel over the client's behavior. The clinician must be careful to support the client, help him or her over the difficulties, but not to minimize or excuse the behavior.
4. Support for abstinence. It might be possible for some gamblers to return to controlled gambling, but I think the risk is too great. The client needs to go to Gambler's Anonymous on a regular basis. Family members should go to Gam-Anon , too.

As the gambler abstains from gambling, they will experience cravings, just like an addict. These cravings are a vital part of recovery. In therapy, they can be used to help the client understand the role of gambling in their lives. Abstinence reveals how gambling filled the holes in the gambler's life. Filling those holes with healthy behavior is a vital part of recovery.
Working with addiction is always frustrating. In some ways, gambling is the worst of the addictions. Substance abusers can avoid their drug of choice fairly effectively. However, with the proliferation of lotteries, casinos, and Internet gambling, the recovering gambler is never far from the scene. Relapses are common with gambling, and are much more catastrophic than with substances. A drunk can go on a bender and then climb back on the wagon. A gambler can relapse and lose $10,000, in a weekend, literally erasing all the good work he had done.

In conclusion, therapy is a mix of educational, supportive, and confrontational treatments. Knowing when to implement them is challenging, to say the least. Gamblers often do enter and maintain their recoveries, although it can be a difficult road there.

Links Between Drug Companies and Psychiatry

2006-04-20T16:52:00.000-04:00
Diagnosis in mental health is detailed in the fourth Diagnostic and Statistical Manual (DSM-IV), published by the American Psychiatric Association. The New York Times today published a report of a study claiming to show links between the authors of DSM-IV and pharmaceutical companies. The report stated,

The researchers found that 95 — or 56 percent — of 170 experts who worked on the
1994 edition of the manual, called the Diagnostic and Statistical Manual, or
D.S.M, had at least one monetary relationship with a drug maker in the years from 1989 to 2004. The most frequent tie involved money for research, according to the study, an analysis of financial records and conflict-of-interest statements.

Honestly, I'm not surprised or upset by the relationship. DSM-IV is published by psychiatrists for use by psychiatrists. It reflects a medical model of mental illness, and most of the experts who work on it are researchers in the biological side of treatment. Most of psychiatry is conducted drug treatment. Psychiatrists prescribe medication. Psychologists, social workers, psychotherapists and counselors conduct psychotherapy. A few psychiatrists still dabble in psychotherapy, but they are a dying breed.

Not surprisingly, then, DSM-IV works fine for medical management of mental illness. It stinks as a diagnostic tool for psychotherapy. Let me show you how it works. A person is diagnosed along five "axes:"

I. Clinical disorders
II. Personality disorders or mental retardation
III. General medical conditions
IV. Psychosocial stressors
V. Global Assessment of Functioning

Axis I disorders correspond to depression, anxiety, and other problems that we normally treat (and are advertised on TV). Axis II refers to personality problems that are long-standing. (Why personality disorders and mental retardation are linked is beyond me.) Axis III details medical status. It's important to know this, as many medical illnesses may manifest the same symptoms as depression or anxiety. Axis IV describes psychosocial stressors in very general terms. Axis V describes a person's level of functioning with a 0 to 100 scale.

So, for example, a person might have the following diagnoses:

I. Major depressive disorder, moderate, recurrent
II. Borderline personality disorder
III. No diagnosis
IV. Problems with the primary support group
V. Current GAF 57

There are myriad problems with this scheme. First, the use of the term "axis" implies that each axis is independent from the others. Nothing could be further from the truth. People with personality disorders, for example, are more likely to have anxiety and depressive disorders than others without personalty disorders.

Second, we don't really know what a "disorder" is. In most cases, there is evidence of both psychosocial and biological causes for a client's complaints. Both psychological and biological treatments are effective for the same "disorders." So, what are we really treating?

Third, this scheme doesn't describe the quality of the client's life very effectively, and that's what we really deal with in psychotherapy. Axis IV, where this should be placed, is very general, and poorly delineated. "Problems with the Primary Support Group," covers a lot of ground, from arguing with your wife to repeated sexual abuse of a child.

Fourth, assessment of these disorders remains rooted in the clinical interview. We've known since the 1950's, with a book by Paul Meehl that clinical interviewing is not very reliable. Unfortunately, psychologists, who are the true experts in assessment, have dropped the ball entirely. We have not generated the kind of data necessary to add psycosocial assessment to the diagnostic manual.

So, why do we need diagnosis at all? We need it to describe what we're treating. We need it to organized our research into better treatment methods. So as a result, we limp along with the diagnostic manuals as written. Hopefully, the next one will be better.

New Orleans Evacuees Suffering from Lack of Health Insurance

2006-04-18T09:56:00.000-04:00
Today the New York Times published a story on the mental and physical health of New Orleans evacuees. According to the story:

The study, conducted by the Mailman School of Public Health at
Columbia University and the Children's Health Fund, is the first to
examine the health issues of those living in housing provided by the Federal
Emergency Management Agency. Based on face-to-face interviews with more than 650 families living in trailers or hotels, it provides a grim portrait of the
hurricane's effects on some of the poorest victims, showing gaps in the tattered
safety net pieced together from government and private efforts.

I haven't been able to find the source on line, so I can't comment on the specifics. However, the overall picture is not surprising. One observation they made caught my eye:

Forty-four percent (of adult evacuees) said they had no health insurance, many because they lost their jobs after the storm, and nearly half were managing at least one chronic condition like diabetes, high blood pressure or cancer.

Our reliance on employer-based insurance coverage continues to fail all of us, but especially the poor. It is infuriating to me that we continue to insist this is the only way, while Western Europe, Australia, and Japan have been able to provide universal coverage to their citizens. The only reason we can't is that we cater to large insurance corporations who like the current system. Remember how they reacted when Clinton proposed changing it?

The current system is completely anticompetitive. Employers negotiate with a few insurers, who are only interested if the employees are a good risk. The employers are interested in insurance that is the least expensive for them. The employees themselves, who will actually use the services are not consulted on what they want.

Once the insurance goes into effect, the only competition that goes on occurs between the provider offices and the insurance company. Basically, the system is this: the physician office employs at least one person to make sure all claims are paid. The insurance company employs people whose job it is to assure that as few claims as possible are paid. They fight it out with each other, raising costs, and slowing down service delivery. It's no wonder we have an incredibly expensive system that nobody likes.

I'm glad that Massachusetts is trying to provide insurance to all, but I'm pessimistic about the plan. State governments don't have the resources to manage a plan like this. Ultimately, as New Orleans is showing us, the solution has to be with the Federal Government.

Professional Ethics and the Clinical Psychologist

2006-04-17T22:19:00.000-04:00

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.

Happy Passover

2006-04-16T19:16:00.000-04:00

I took a few days off from blogging to celebrate Passover. Passover is a holiday observed entirely in the home. Jews who don't keep kosher, who don't observe the Sabbath, who may only go to synagogue twice a year, still celebrate Passover enthusiastically. It's a wonderful holiday. We have a sumptuous meal, and re-tell the story of the exodus from Egypt, praising God for helping us escape from Egypt. Since we drink four cups of wine in it, there is usually great merriment associated with it.

Passover lasts for eight days. It's traditional to have two seders on the first two nights of Passover. Mostly, people hold their own on one day, and visit someone else's seder on the other day. For all eight days, we are prohibited from eating anything that is leavened. There are also other restrictions, based on where your family comes from. Ashkenazic Jews (from eastern Europe) don't eat rice, while Sephardic Jews (from the Mediterranean) do eat rice.

So, we eat a lot of matzah, which is basically a cracker. It's absolutely tasteless, and we all love it. Every time we bite into a matzah, we recall all the joy of Passover. It's a testament to the power of classical conditioning.

Psychology and Homosexuality

2006-04-11T22:00:00.000-04:00
A rant against the American Psychological Association cropped up here. I'm not sure who wrote it, but it turned up on the PsyUSA mailing list. Now, I'm not an APA member, so I don't care what happens to them, or what people say about them. But I do care about my profession and some of the nonsense that this rant is spewing.

For the record, I dropped my membership a few years after they turned up the screws on clinical psychologists, requiring a surcharge on our dues. I found myself paying much more money than APA was worth, and watching APA ignore the real threats against psychology. As far as I was concerned then (and now), the real threat wasn't managed care, it was the depressed fees we were being paid. Most practitioners in private practice would agree with me now.

Anyway, this rant screamed, "American Psychological Association has gotten out of control in its politicization of psychology." Apparently, according to the paranoid who wrote this:
Psychologists, it seems, soon may not be allowed to administer mental therapy for persons experiencing homosexual tendencies and wanting to change their behavior, without getting their license from the American Psychological Association revoked.
And mental therapy is....?

The ranter is referring to reparative therapy, i.e., efforts to make gay people straight. Back in the 60's and 70's, I recall some gruesome behavior therapy attempts, using electric shocks (no, not electroshock therapy; that's something else). It didn't work. No procedure has been documented to change sexual orientation. Certainly not the modern fundamentalist efforts. None of the groups who allegedly can change sexual orientation have provided any good data to back their claims.

I'm sorry to inform the author that the APA is not a licensing body. In the USA, licensing of psychologists is done at the state level. The APA does write the ethics code adopted by most state boards, but the APA's ability to manage their own members' ethics is minimal. All they can do is to either censor someone or expell them from the APA. Big deal. I'm not a member and I don't care.

Another piece of misinformation gets added:
the funny thing is that 30 years ago, the APA had homosexuality classified as a mental disorder.
The American Psychological Association never classified homosexuality as a mental disorder. It was the American Psychiatric Association, and entirely different body, and one that has been quite hostile to organized psychology.

This person goes on, even more ridiculously,

Shannon Love, also a blogger, 20 years ago was "denounced as a [crypto-fascist] for asserting that [she] thought that a lot of homosexuality had a physiological basis."

Back then, she claims, liberals believed that there were no biological roots to such things as homosexuality, because saying that was reminiscent of the biological engineering programs of the Nazis.

But in the '90s, defending homosexuality as something as unchangeable as the color of your skin became more "politically expedient," said Love.
I have no idea who Shannon Love is. If she was "denounced as a [crypto-fascist] 20 years ago, I'm sorry. To charge that liberals are being politically expedient to accept homosexuality is silly. Just check the results of the last election, when gay marriage wound up on several state ballots.

The thinking on the origins of homosexuality has certainly changed over 20 years, but the reason it's changed is that there is more data available.

Apparently, the ranter doesn't think so:

The human "sexual orientation gene," if there is one, has not been found.

According to gene-watch.org, the only attempt to do so, by Dean Hamer, was controversial and is now under investigation by the federal Office of Research Integrity.
I checked this gene-watch.org web site, and I didn't find the charge against Hamer. But I did find some nonsense. They also say:
The claim that genes account for the transmission within families of schizophrenia, bipolar manic depression, and alcoholism have all been contested, and most such reports have eventually been withdrawn.
Maybe on their planet. Here on earth, it is recognized that genetics play a critical role (but not 100% role) in all of those illnesses.

But what both this ranter and gene-watch.org do is set up a straw horse. I don't think anybody believes that there is one gene controlling homosexuality. Instead, our sexuality is controlled by a complex interaction of genes, with potential interplay from both pre- and post-natal influences.

Of course, when we're all done, the ranter has to add:
Regardless of the true nature of the causes of homosexuality, the anecdotes described above show what can happen when emotions and agendas get in the way of calm, rational debate.
A clear case of the pot calling the kettle black.

There is plenty of good data about homosexuality and other sexual minorities available here. Wikipedia has an unfinished section on biology and sexual orientation, which has some good references.

The Scientist as entrepreneur

2006-04-10T14:17:00.000-04:00

The Ewing Marion Kauffman Foundation released a study today, entitled, The Knowledge Filter and Economic Growth: The Role of Scientist Entrepreneurship. It indicates that that basic research does pay off for future economic growth. Businesses are frequently started by the researchers to exploit their findings. The press release summarizes the main conclusion of the study by saying:
"The study by Indiana University researchers reveals that cancer scientists,
in addition to commercializing their research through licensing, are starting
new businesses, which largely go unrecorded by existing innovation
commercialization tracking systems. In fact, more than one in four patenting
National Cancer Institute (NCI) scientists within the researchersÂ dataset has
started a new firm. These scientist-launched start-ups are the sleeping giant of
university commercialization."
This doesn't surprise me that much. Basic research is always what it says it is. Basic. Our imaginations are the only limitation of how much we can build on it. But, there is something that is missing, and that worries me very much.
Not alltherapeuticss are patentable. Psychotherapy, speech therapy, and physical therapy, are all examples of therapies that cannot be patented. If we focus our research on patentable therapies, other, often less expensive, treatments go undeveloped. For example, it is widely accepted that psychotherapy reduces risk of relapse in adults with either depression or anxiety. Consequently, the preferred treatment is combined pharmacotherapy and psychotherapy. Yet, cognitive-behavior therapy, a well-researched treatment for depression and anxiety, has remained largely unchanged since it was originally proposed by Albert Ellis in the 1950's. Both Meichenbaum and Mahoney laid out the basic research in the 1970's. Beck's classic Cognitive Therapy of Depression was published in 1979.
Since then, federal support for research in behavioral health has eroded and there's been little progress. The money has been in drug research because that is profitable. If we continue to focus on what is easily commercialized, we will continue to see the erosion of non-drug therapies. Ultimately, we need more support for basic research in areas that are not commercial.

Humor in Psychotherapy

2006-04-06T10:20:00.000-04:00

I like to use humor in therapy. I use a lot of cognitive techniques, and therefore challenge my clients' beliefs about the world. Often, humor is the best way to get people to reevaluate their beliefs. This is one joke I love, but will never tell a client:

A young psychologist obtained his license, and opened a private practice in a building where an older, well-established psychologist practiced. Over time, they got to know each other, and fell into a pattern of coming and going from the office at the same times, often chatting for a few minutes in the morning and the evening.

One day, the young psychologist noticed another pattern. Every day, they both walked into the building with a spring in their step and lots of energy to start the day. By the end of the day, the young psychologist was exhausted. His shirt tail was out; his tie was down, and was absolutely exhausted. The older psychologist still had a spring in his step and was still full of energy.

Finally, the young psychologist asked about it. "How do you do it?" he asked. "I spend all day listening to people's problems, and it just wears me out. I'm exhausted at the end of the day, but it doesn't seem to bother you at all."

The older psychologist looked at the younger psychologist and asked, "You listen?"

Oops. Microsoft strikes again

2006-04-04T18:55:00.000-04:00
I noticed today that my posts have been hidden by the footer when viewed in Internet Explorer. It worked fine in Firefox. I reloaded and tweaked the template and it seems to be working now.

Physics and Psychophysics

2006-04-04T10:13:00.000-04:00
Over at Uncertain Principles, I got a few chuckles over the description of the activities of bored graduate students. University labs are the same all over. It was also neat to see that a student in his lab had reinvented the psychophysical experiments that gave me the name of this blog. Seems that the jnd for color perception is quite small.

Prayer and Psychology

2006-04-03T18:04:00.000-04:00
Much of the shouting has died down since the release of Benson's much heralded study of the effects of prayer on the recovery of people going through heart surgery. Over at Science Blogs, there was much conversation over whether or not it was worth the trouble to perform a study where the outcome was obvious. PZ Meyers was especially critical.

The New York Times published several letters about the study today. Some contained the predictable rationalizations; other pointed out that prayer is beneficial to the one who prays, not to the object of the prayer.

Although, as I said in a previous post, negative results are never the final word, it is still true that the evidence that God answers prayers of petition is pretty weak. I don't think most people are surprised by this result. I believe in God, I pray, and I wasn't in the least bit surprised.

I never thought that prayers to God directly brought changes to this world. I live near a bunch of Civil War battlefields. Both Federal and Confederate armies prayed fervently for God's support. If prayer "worked," the slaughter on those battlefields never would have happened. Besides, if both sides pray for their side to win, what does God do then?

More facetiously, if God answered prayers of petition, how many 15 year old male virgins would there be?

I'm Jewish, and I attend a Reconstructionist synagogue. Reconstructionism is an offshoot of the Conservative movement, and falls somewhere to the liberal side of the Conservative movement. (Or, the traditional side of the Reform movement.) Although I have differences with Reconstructionism, I'm more comfortable with this approach than any other. It balances rationalism with tradition.

In the traditional service, there is a prayer said for the sick during the morning service, known as mi sheberach. It is a petition for God's intersession. The Reconstructionists added in a line praying for the physician to have "wisdom and sound judgment," but the prayer for intersession is still there.

So, what should I do? Should I demand that the prayer be omitted? No, and here is why:

First of all, our prayer book is an historical record, which links me to a very long history. Part of that history is the belief that prayers to God are answered. I may no longer believe it, but it's still part of me. It links me to my community.

Second, when I pray, I am reminded of my values. For many Jews, a central part of our belief system is that we must be partners with God in creation. That means that we have an imperfect world, and have to work things out for ourselves. God is not going to stop war or heal the sick. We have to do it ourselves.

So, when I say--or listen to--mi sheberach I am reminded that healing will make the world a better place. As I pray--sometimes--I sense God's presence, and am reminded there is more to this world than getting through the day. I am inspired to commit myself to my community and to work to heal others.

Mental Health Parity and Insurance Costs

2006-03-30T16:18:00.000-05:00
Parity in mental health and substance abuse coverage is a goal for many advocates for the mentally ill. Normally, insurance coverage for treatment of so-called "mental illnesses" (I'll deal with that term on another day) and addictions has it's own sets of limits, in some cases draconian. Parity in mental health and substance abuse coverage means that people have the same co-pay, deductible, and visit limitations as they do for traditional medical care.

The argument against parity has been that it would increase insurance costs significantly. The fear has been that people would sail into long-term therapy or stay in the hospital indefinitely, leaving insurance companies to pick up the tab. This article, by Goldman, et al., (there are 14 authors!) in The New England Journal of Medicine challenges that assertion.

The background is simple. In 1999, President Clinton directed the Office of Personnel Management to ensure parity for federal employees. Parity was established on January 1, 2001 for all 8.5 million enrollees in the federal system. This figure includes retirees and dependents along with the federal employees.

The authors matched 9 federal insurance plans with parity to 9 similar non-federal insurance plans without parity. They matched them on features of the plans and geographic location. They then compared the costs of the plans over the years 2000 (prior to parity) and 2001 (after parity).

From 2000 to 2001, costs of both plans rose the same amount. Had parity increased costs, the plans with parity would have increased more than the plans without parity. Because they did not, Goldman, et al., concluded that parity did not increase insurance costs.

I have a couple of of quibbles with this study. First, I'm not convinced that they matched the federal and non federal plans very well. I'd feel a lot better if they matched the plans based on the demographics of the enrollees. We know that variables such as socioeconomic class can influence rates of mental illness and substance abuse.

Second, I'm not sure that one year is enough to see a trend in costs. The major costs come from treatment of chronically mentally ill, especially in inpatient settings. That might take several years to emerge.

Finally, I'm uncomfortable with the statistical analysis. Part of it is my problem. They used a technique called "difference-in-differences" analysis, and I'm unfamiliar with it. Googling indicates that it's frequently used in epidemiological research, but I'd feel better with a parametric test, such as ANOVA. Their willingness to base conclusions on negative results furthers my uneasiness. However, they do have this to say about it:

A finding of negative results always raises the question of whether the effect of parity on use and spending was really limited or whether the evaluation lacked the necessary power to detect an effect. Two factors lead us to believe that the effect really was limited: the estimated differences between the results for enrollees in the FEHB Program and comparison enrollees were relatively small in magnitude. The sample sizes used in the analysis were large and were sufficient to show significant effects of similar policy measures, such as the effect of carving out mental health and substance-abuse care while holding the benefit design constant. (p.1384)

It's not a bad argument, but it's still somewhat shaky. On the other hand, there is an argument supporting parity which has been well documented. Providing mental health and substance abuse treatment costs brings down the costs of other medical services, especially in primary care.

Overall, this study throws the ball back into the anti-parity court. On a logical basis, it's really up to them to show that costs do increase. Goldman, et al., have shown, if nothing else, that the data is out there, just begging for analysis.

Unfortunately, I doubt we'll see any more data analysis. The belief that we need to save money on mental health treatment is very entrenched, and it seems to fall into the don't-bother-me-with-the-data-when-my mind-is-made-up category. It's like the belief that raising the minimum wage eliminates jobs. Every time we do it, the economy booms, but people still repeat that objection over and over. Still, this study is a start in a long overdue discussion.

Red Bull + Vodka = Bull

2006-03-29T17:11:00.001-05:00
An interesting article in Seed Magazine, entitled, A False Tolerance for Red Bull, tests a popular misconception on college campuses. Students have been mixing vodka with Red Bull, an energy drink, believing that Red Bull moderates the effects of alcohol.

It doesn't. Drinking Red Bull does give the drinker a little energy, so it moderates such internal sensations of intoxication, as sleepiness. In the study, objective measures of reaction time and fine motor coordination still revealed impairment. The person's ability to judge their own intoxication is more impaired. There's a serious risk they'll drink more, miscalculation how drunk they are.

Mixing Red Bull and vodka may make for a good-tasting drink, but it can also raise alcohol intake. In turn, it may increase risks related to intoxication, such as drunk driving or date rape. I hope this data gets publicized on campus, not that many students will listen until it's too late.

"Deconstructing" Psychology

2006-03-28T09:07:00.000-05:00
Every time I hear about "deconstruction" I feel old. Granted, I'm coming up on 60, but I still do keep up. Well, sorta. I still haven't gotten an MP3 player or a Blackberry yet.

Anyway, I encountered an article entitled, "Theorising Critical Psychology In Psychiatric Practice: Six Voices Interrupting Pathology" by Burman, et al., on the on the Social Practice/Psychological Theorizing web site. In it, the authors say,

Critical Psychology is the Practical Deconstruction of every attempt to normalise some kinds of behaviour and experience and to pathologise others.
Psychology is constructed within the horizons of capitalist society to enable that society to run more efficiently, and it constructs within that society its own images of pathology. Part of the political activity of challenging the construction of psychology is the unravelling of what we have made. The process of critique is also a process of deconstruction. It must include a practical political alliance with all those who suffer psychology and who are starting to refuse the way they have been constructed as pathological. It is a political question that calls for practical deconstruction of the theories and apparatus of the discipline of psychology. (p. 4)
This kind of nonsense really annoys me. First of all, it mischaracterizes those of us who practice in the field. We're a lot more heterogeneous than Burman, et al., let on. I characterize my politics as left of center. I've known psychologists much further left of me and some psychologists who are a little right of Atilla the Hun. The American Psychological Association (I'm not a member) has certainly taken some left-wing positions, such as support of abortion rights. To argue that, "Psychology is constructed within the horizons of capitalist society to enable that society to run more efficiently," is simply silly. Our first responsibility is to our clients. Our second responsibility is to society.
We work to help our clients function more effectively within society, but it is within the context of their goals, not ours. In some situations, we do help our clients become better workers. An employee with a personality disorder may cause chaos on the job, and we owe it to both the client and the employer to stabilize their behavior.
In other situations, we don't help the employer. I doubt there is a practicing clinician who hasn't tried to help a client work less overtime so they could be more attentive to their loved ones. That certainly doesn't help the employer.
Juggling our priorties can sometimes be a problem. We may help clients to get over losses when they have been asked to leave a social club. But if that client decides to go back there with a gun, we have an obligation to society to stop them by notifying the police and having the client hospitalized. Balancing a person's rights against society's is complicated and messy. When rights conflict, we may be forced to do what causes the least damage. Politics and power be damned.
Politics, power, and feminism always get mixed together in deconstructionist writings, and Burman, et al., are no exception:
Because models of development privilege the culturally masculine, they position women, black people and even children as culturally deficient and inferior. Their experiences are treated as mere steps on the evolutionary ladder to modern western developmental maturity. We can challenge this by pointing out the covert ways women and black people and children are considered less rational, or madder, than white middle class men.
The problem here is two-fold. First, psychology is rapidly becoming a female profession, so why culturally masculine concepts should be retained is beyond me. Second, historically, the field has been very concerned with filtering out sexual and cultural stereotypes in diagnosis and treatment. Hollingshead and Redlich (1958) were probably the first to show that people with of lower socioeconomic status are more likely to be diagnosed with more serious pychiatric illnesses.
So, it's an old problem and we continue to recognize it. We're a long way from having completed the process, but a fascinating article by Hyde (2005) deals with gender similarity and differences in a new and exciting way. This article can be found online by clicking here.
I could rant and rave about a lot of the nonsense in this paper, but I'll make one final point. There is no doubt that culture, perception, and mental health interact. Certainly, our definition of mentally ill behavior has changed over the years. However, Burman, et al., refer to psychotic speech or thought disorder as a "a construction of the psy-disciplines" (p. 6-7). That's nonsense. Anyone who has spent 5 minutes talking to a floridly psychotic person can see that there is something truly wrong. I have never encountered any evidence to suggest that a thought disorder in any society was ever truly accepted as normal or desirable.
There is such a thing as objective reality. Because reality is complex, it's often hard for us to differentiate it from our prejudices and stereotypes, especially in my line of work. But, it's there, and I believe that the closer we come to reality, the better we function. That's a big part of the way I do therapy.
References
Hollingshead, A. B,. and Redlich, F. C. (1958). Social class and mental illness. New York: John Wiley.
Hyde, J. S. (2005). The gender similarities hypothesis. American Psychologist, 60, 581-592.

Who is Operant and Why Does He Need to be Freed?

2006-03-27T15:13:00.000-05:00
I mentioned in my last post that the title for my blog was drawn from one of the first psychological concepts I learned in college. My name comes from my graduate training in behavior therapy.

An operant is any overt behavior, which is potentially controlled by either stimulus, or a consequence. The stimulus is called an antecedent, because it happens before the response occurs. The consequence is either reinforcing or punishing, which means that it affects the frequency of a behavior. A free operant is a behavior that happens without systematic application of antecedents or consequences. Some might say that my views are free operants, depending on how worthy they are of being ignored. Still, it's a pleasure to write about them and to explore them myself.

So with my nom de blog, I pay tribute to my graduate training. Make no mistake about it. I hated the graduate school. After graduation, I still had to return to campus on occasion. I felt my anxiety rise the moment I walked into the psychology building. It was a tribute to the power of classical conditioning.

Nevertheless, I got excellent training there. I passed my licensing exam on the first try, and not too many people could say that. I passed because of the education I got there.

Sadly, I have to post anonymously in order to protect both my clients and my employer. I don't want my clients to worry that they might appear on the internet. The views that I post are mine alone, and not my employer's.

Who am I?

2006-03-26T16:02:00.000-05:00

I am a psychologist, and I practice in central Pennsylvania. I've been doing this a lot of years, having interned in the 1970's. I've taught, I've worked in institutions and hospitals, and I've done private practice. Right now, I work in an outpatient clinic in a good-sized corporation.

I hope to use this blog to discuss clinical practice. I won't be discussing "cases," because I won't violate my clients' confidentiality. Instead, I'll be talking about the science of psychotherapy and the life of a practicing psychologist.

Is psychology a science? Absolutely. It's roots are firmly embedded in empiricism. However, the practice of clinical psychology is not a science. Neither is medicine.

No medical or clinical endeavor can be a science, because healing is not systematic. The practitioner must treat the problems that come in the door, regardless of whether the research is available or not. Often, treatment decisions are based on hunches or past experience, hardly systematic or empirical. The best we can do is make each client into a one-person experiment. Sometimes, even that's difficult. We do the best we can if we want to make a difference.

A difference? Sounds like the title to this blog. That brings me to why I selected Just Noticeable Differences for the title of this blog.

When I was a lowly undergraduate, one of the first psychological concepts I learned was the "just noticeable difference," or jnd. It comes from the psychology of perception and refers to the smallest change in a stimulus that can be perceived. For example, if I compare two lines, what is the smallest difference in their length that is perceptible?

The jnd is one of the first, if not the first, empirically based psychological concept. It's still important today, as we try to construct readable gauges and other displays that reflect change.

Change is what I try to elicit from my clients. I'd like to think that I get a few jnd's of change from most of my clients.