Father's Age and Serious Mental Illness

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:

1. 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;
2. The risk factors are consistent across world cultures;
   
3. It's consistent with the data on other genetic diseases, as I mentioned above; and
4. 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

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

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

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

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

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

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

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

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

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

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

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

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

First, let me summarize:

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

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

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

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

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

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

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

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

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

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

Insight and Psychotherapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Goal-Setting and Marital Therapy

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

'Tis the Season of Greed and Gluttony

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

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

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

Reparative Therapy

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

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

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

'Nuff said.

Love, Marriage, and Enmeshment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Marijuana Protects against Alzheimer's?

This just popped up on the Psychiatric Times:

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


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


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


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


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


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

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

Distrusting Experts

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

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

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

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

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

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

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

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

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

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

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

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

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

A New Look

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

Internet Addction or Compulsive Behavior?

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

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

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

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

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

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

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

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

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

A New/Old Look at Psychoanalysis

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

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

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

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

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

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

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

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

The Lancaster School Shootings

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

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

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

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

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

More Complaining about Evidence-Based Treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

Obsessive-Compulsive Disorder

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

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

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

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

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

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

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

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

Update

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

Here we go....

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

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

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