JND in Top 100 Mental Health and Psychology Blogs

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

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

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

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

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?

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

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

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

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

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

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

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

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

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

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

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

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

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

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.