Sick Transit

I haven’t read Eckhart Tolle, but isn’t he supposed to have discovered the secret of enlightenment and been perfectly content living on a park bench? If so, why does he need to charge $100-200 a seat for his lecture?

Via BPS Research Digest, Scientific American Mind has an interesting article about efforts to cure pedophilia.

One fact often missing from public discussion is that, from the beginning of research in this area in the late 19th century, psychologists have distinguished between two different types of pedophiles:

Krafft-Ebing also pioneered a distinction between hard-core pedophiles–those whose predilection came to the fore at puberty–and other forms of child abuse in which children are used as substitutes for adults. These pedophiles turn to children later, after an adult relationship has failed or they realize that the possibility of one is remote.

Among the latter class are “situational molesters.” These people are usually incapable of having relationships with an equal–perhaps because of a mental disability–or may turn to children after experiencing frustration or humiliation in an adult relationship.

This distinction seems fairly critical for public policy discussions–e.g. whether pedophilic acts can be deterred, or the recidivism rate of pedophiles–but is not something you’ll generally hear much about.

The other key distinction is between pedophilia as a psychological condition–sexual attraction to children–and the actual act of molestation. There are likely additional factors that play into the transition from thought to deed:

A general lack of inhibition rounds out the picture: pedophiles may suffer from psychosis, poor impulse control or alcoholism. Supporting the notion of pedophiles as impulsive, a research team led by psychologist Ronald Langevin of the University of Toronto discovered differences in an area of the frontal lobe in men who molest children as compared with normal men. This region of the brain is critical for impulse control among its other, higher-level reasoning functions.

How many pedophiles are there out there who don’t molest, because they have sufficient inhibition control? And what could we learn from them for the treatment of sexual offenders? We’re unlikely to find out anytime soon, since individuals in that condition are unlikely to come forward and identify themselves.

The second group above–the ’situational molesters’–are more treatable and less of a danger to society than the hard-wired pedophiles; OTOH, the latter are more deserving of our pity, because innate sexual orientation is a nearly impossible thing to change. That in no way excuses the acts of offenders, of course; but the need to protect children from the manifestation of this disease should not blind us to the misery of those who have it.

Welcome to “Dan Talks About Stuff He Doesn’t Know Jack About.” In today’s episode, I will discuss the Journal of Counseling & Development article Models of Disability: Implications for the Counseling Profession (Smart, J. and Smart, D.; Winter 2006).

The article describes four different models of disability: the Biomedical model, based on diagnosis and categorization of the physiological characteristics of disability; the Functional and Environmental models (described as different models, but not really distinguished in the article), which analyze disability in the context of functional expectations and interactions between a person and their environment; and the Sociopolitical model, which views people with disabilities as an oppressed minority whose ‘otherness’ is socially constructed, and who do not currently receive their full civil rights.

The authors advocate the use of all the models in appropriate circumstances, although their strongest criticism is reserved for the Biomedical model because of its failure to address the emotional needs of individuals with disabilities, or society’s responsibility to them.

Because of my own very limited experience with the issue, some of my remarks are likely to be obtuse and/or tactless. However, the subject interests me enough that I am going to dive in anyway. I apologize in advance if I step on any toes.

First off, the Biomedical model. As the authors acknowledge, “no one, including proponents of the other models, suggests totally abandoning the Biomedical Model.” Medical treatment of conditions causing disability requires categorizing people according to disability, analyzing the patient independently of social context, etc.

The problem starts when the biomedical nature of disability is taken as the only valid lens through which to view the issue. As the Smarts point out: “The degree of prejudice and discrimination experienced or the lack of accommodations is typically not considered when medical professionals determine the level of severity of the disability or render a percentage of impairment.” To give an example in less loaded language, two people who have both lost the use of their legs may be experiencing the same biomedical condition; but if one lives in an industrialized society where motorized chairs are commonplace, and the other lives in an impoverished rural area without electricity, their actual levels of disability are very different.

By the same token, environmental factors–e.g. whether or not the public (through government or private charity) provides resources for those who cannot afford accomodations, whether jobs and public spaces are accessible–make a real difference in the level of disability that people with the same medical condition actually experience.

The Smarts also make a broader point:

The Biomedical Model of disability does not provide a strong basis for the treatment and policy considerations of chronic conditions, which include most disabilities. Because of the long history of the two-outcome paradigm of medicine–total cure or death of the individual–medical professionals work best with acute injuries rather than chronic, long-term disabilities. Vestiges of this two-outcome paradigm remain in insurance payment policies, which dictate that payments for services–such a counseling–are withdrawn once medical stabilization has been acheived and progress toward a full recovery has terminated.

The acute-care focus of the medical profession is a flaw on which ‘alternative medicine’ feeds. There’s been a movement in the last few years to put more emphasis on prevention, maintenance, etc. but cultural changes like that happen over generations.

This is turning into an incredibly long topic, so I’m going to pause here for now, and pick up in another post. Stay turned (or, if you prefer, tune out) for more posts on this subject.

An example from a Harvard magazine article:

Ludicrous? A bank in South Africa performed a randomized trial on direct-mail advertisements for loans and found:

Via Tyler Cowen.

I’m not sure who originally coined the term ‘praise sandwich’, but it describes a well-known principle: when you need to deliver criticism (or more generally, any difficult news), start and end with something positive.

Researchers have established that this same principle is important in psychiatry:

Common sense, but perhaps easy to lose sight of in the artificial context of therapy.

Via Drum, Jonathan Rauch does a follow-up interview to his essay on introversion, which I blogged about some time back.

It’s been some time since I’ve written about the medical model of psychiatry, when I was reading a book by neo-Freudian Elio Frattaroli. Just today, however, I encountered a passage about the medical model which I thought was insightful enough to be worth sharing. It was from an article by James Hansen in the Fall 2005 issue of Journal of Counseling & Development, with the slightly dramatic title The Devaluation of Inner Subjective Experiences by the Counseling Profession: A Plea to Reclaim the Essence of the Profession. Hansen argues that the counseling profession needs to reclaim the value it has traditionally given to internal subjective experience, which he believes has waned over the past quarter-century due to the constraints of counselor education, the prevalence of the medical model, and social constructivist theory.

Hansen argues that medicalizing psychiatry does not necessarily mean–and should not mean–defining conditions solely in terms of symptoms:

I don’t know to what extent Hansen is attacking a straw-man here, since I doubt that anyone with real-world experience with depression is naive enough to believe that all depression can be treated identically. However, I think his words are a good corrective to simplistic, DSM-focused diagnosis.

Kevin Drum links to an op-ed by Florida State University psychologist Roy Baumeister, who has just undertaken a review of psychological studies on the subject of self-esteem. His approach exemplifies the fundamental problems with quantitative and symptom-focused psychology.

Baumeister’s conclusion, in a nutshell, is that self-esteem does not produce any measurable improvement in performance, relationships, or social behavior. The problem with his review is clear from this paragraph:

The flaw here is glaring: a person with genuine self-esteem does not have a “defensive or know-it-all attitude”, and there is no conflict between self-esteem and humility. In fact, a person who truly ‘accepts and loves’ themselves (to borrow Baumeister’s phrase) is not ashamed of their own limitations or afraid to own up to them.

But there’s no way to measure true self-acceptance in a survey. Instead, researchers ask respondents to rate their own attributes and abilities. But if, as popular wisdom holds, people with low self-esteem are the most given to exaggerating their own accomplishments, this will clearly produce skewed results.

It’s troubling that Baumeister doesn’t even acknowledge this pitfall. It shows two major blind spots: 1) the over-simplification that comes from reducing a psychological attribute to a quantifiable survey, and 2) unwillingness to recognize the power of repression.

On the positive side, Baumeister does show the fallacy of shallow attempts at raising self-esteem, e.g. grade inflation. Meaningless praise and lack of consequences may raise surface self-regard, but they do nothing for fundamental self-acceptance.

Unfortunately, Baumeister’s review makes no such subtle distinctions, concluding instead that the solution is to focus on “self-control and self-discipline” instead of self-esteem. In other words, to replace one form of surface control with another, without ever addressing the underlying psychological issues. It’s sad that this sort of naive, symptom-focused reasoning represents the mainstream in psychiatry 100 years after Freud.

Update: Article 19 has a good (and far pithier) take-down of Baumeister as well.

I am in the middle of reading Healing the Soul in the Age of the Brain, a fascinating book by neo-Freudian Elio Frattaroli arguing for psychotherapy as the dominant approach to mental health treatment.

I’m only a quarter of the way through, but I wanted to write about a few things that have struck me so far. They are: 1) Frattaroli’s rejection of scientific materialism; 2) the economic costs of the psychotherapeutic approach; and 3) the ideological safety of what Frattaroli calls “the Medical model.”

Continue Reading “Viennese If You Please”

I am in the middle of reading Healing the Soul in the Age of the Brain, a fascinating book by neo-Freudian Elio Frattaroli arguing for psychotherapy as the dominant approach to mental health treatment.

I’m only a quarter of the way through, but I wanted to write about a few things that have struck me so far. They are: 1) Frattaroli’s rejection of scientific materialism; 2) the economic costs of the psychotherapeutic approach; and 3) the ideological safety of what Frattaroli calls “the Medical model.”

First off, a brief summary of Frattaroli’s thesis. He describes the current mindset of psychiatry as a “Medical Model” focused on prescribing drugs to treat an illness. While he does believe that there is a place for psychotropic medications, he states:

Unsurprisingly, he calls this the “Psychotherapeutic Model.” While I am inclined in large part to agree with him, I think that there is one glaring flaw in his argument, and a couple of other issues that need addressing.

1. Scientific Materialism

Frattaroli explicitly rejects “scientific materialism” in those very words. He believes that “there are very real differences between brain, mind, and spirit”, and that the idea that our psyches are exclusively the result of brain function is based on “a general misunderstanding of the nature of science.” (6,8)

His defense of this position–including charges of “articles of quasi-religious faith cloaked in the language of science”–is eerily similar to Intelligent Design argumentation. (8) The psyche is too complex and mysterious to be just neurons, he feels; and since science can’t actually prove that there’s no soul, “we cannot do better than to have faith in our own authority, and base our beliefs on what makes the most sense, and feels most deeply right, to us.” (14)

Just like the IDers, Frattaroli forgets that the burden of proof is on him to prove the existence of the soul, not the other way around. He does not give a single example of a psychological process that could not be the result of brain function. We know from chaos theory that a set of simple algorithms connected in feedback loops (which is what a brain is) can produce incredibly complex results. And so, despite what Frattaroli says, we don’t need to prove that the soul doesn’t exist. Since neurons provide adequate explanatory cover, Occam’s Razor tells us that adding a soul into the mix is a bad hypothesis.

Interestingly, this soul proposition is actually completely unnecessary to Frattaroli’s argument. Given that the brain is a chaotic system, it’s quite reasonable to argue that psychotherapy–i.e. language, a complex and dynamic brain process–is a much more powerful healing method than the one-trick pony of medication. Instead, by arguing on the basis of a nebulous soul, Frattaroli makes it easy for the Medical Model crowd to dismiss him as an unscientific crank.

2. Economics

It’s no coincidence that the increased accessibility of mental health care has paralleled the rise of the Medical Model. Frattaroli savages managed care for limiting hospitalization and promoting medication over psychotherapy, but he also recognizes that a stay in a mental hospital costs $40,000 a month. (97) If mental health care were routinely conducted the way that Frattaroli wants, most insurance simply wouldn’t cover it. That shouldn’t stop him from arguing for what he believes to be the best treatment, of course; but it might at least temper his rants against a profession that has chosen the attainable over the utopian.

A related issue is time. Frattaroli says that “two months is about the average time it takes for a hospitalized patient to become meaningfully engaged in treatment.” (33) If the alternative is home disability, then this may not matter much. On the other hand, if medication can return a patient to the workforce or other productive activity, then the multi-month hospitalization that Frattaroli suggests incurs not just a direct cost but also a significant opportunity cost.

3. Religion and Society

Freud was no fan of religion, and for most of the 20th century, traditional religion responded in kind. While this antagonism is regrettable, it also seems understandable in light of Frattaroli’s description of psychotherapy as an instance of “a universal process of spiritual quest, the need for which seems to be part of the human condition.” (76) Religion has traditionally regarded such quests as its own domain, and will naturally take poorly to psychiatry’s transgression on its territory, especially since psychotherapy involves a process of deconstruction that is often anathema to religious faith.

This tension seems to have abated since the rise of the Medical Model, which imposes less of a requirement on the patient to question their beliefs. Overall social acceptance of psychiatric illness has increased as well, now that treatment is no longer such an emotional threat.

Frattaroli would probably say that this is just an expression of the universal fear of–and hence resistance to–consciousness, and he would undoubtedly be right. However, this is still an obstacle that psychiatry will have to face if it is to change as Frattaroli suggests.

Despite the above criticisms, I want to re-emphasize that I agree with Frattaroli’s fundamental idea, and–based on my reading so far–would highly recommend the book.

One of the things that bothers me about 12-step programs is the first two steps (okay, maybe that’s two things, but they’re of a piece):

1. We admitted we were powerless over [the addiction] - that our lives had become unmanageable.
2. We came to believe that a Power greater than ourselves could restore us to sanity.

Healing from addiction is fundamentally about taking control of one’s own life, and recognizing that one has the power to make changes. Step 1 seems to run completely counter to this.

And as a secular humanist, I am deeply troubled by the attribution of one’s personal power to any force outside oneself. So I find Step 2 highly suspect as well.

Meia and I watched 28 Days tonight (which I highly recommend… excellent mix of seriousness and dark humor), and it got me thinking about that issue. The turning point of Sandra Bullock’s character was when she recognized that she had a problem; and not only that she was addicted, but that her attitudes towards life–particularly the way she closed herself off from others–kept her addicted.

So I think that’s the real kernel of recovery from addiction. Not recognizing one’s powerlessness over one’s addiction, but rather realizing how one renders oneself powerless through one’s attitudes and emotional habits.

Step 2 should be coming to believe that the remnants of sanity are within ourselves, that deep down we retain the healthy person we really are. (Meia just pointed out that Jampolsky described it as “recognizing that we are whole.”)

Step 3 would then be identifying the parts of ourselves that contain that kernel, who we really are. (Meia just pointed out that in the original AA, this step is about accepting the “care” of God. So the important part is learning to accept love and care, from others and from oneself. I think she’s right on.)

Step 6 would be, not a readiness to have God remove our defects, but rather a readiness to make changes. I’m not sure what Step 7 would be; it doesn’t seem that different from Step 6.

(The invaluable Meia chipped in again. She suggests that Step 7 is about forgiveness. Makes sense to me. So in a humanist context, I guess that Step 7 would be forgiving oneself, letting go of guilt.)

Step 11 would be, not through prayer, but through getting in touch with one’s feelings.

I imagine I must not be the first person to try to make a non-theistic version of the 12 steps. But the real issue is not just to change wording around, but to eliminate the ideas of guilt and surrender of will, and replace them with empowerment and love.

Guilt may motivate a person to break an addiction short-term, but changes made by guilt aren’t long-lasting. I can’t help making the parallel to the religion I grew up in, Jehovah’s Witnesses. Since so much of the motivation is based on guilt, it requires constant reconditioning to keep people guilty, and hence motivated.

Obviously a 12-step program is very different, since the goal is to help people, not to take advantage of them. And I don’t think that 12-step programs are all guilt-based; I know people who’ve been through them who are not guilt-based thinkers at all. Still, I think that if a person is already strongly motivated by guilt, some of the ideas in the 12 steps might serve to worsen that problem instead of helping to heal it.

E-mail is a depersonalizing medium, and the Internet is full of liars, right?

Just an interesting tidbit to counter that stereotype:

Pretty damn dishonest bunch of students over all… but it’s interesting that e-mail actually had the lowest number of lies. Tyler Cowen suggests that it’s because e-mail leaves a permanent record. Makes sense to me.

The New Yorker has an article about group grief counselling after major disasters, such as 9/11.

The key problem:

The article’s suggested replacements are cognitive-behavioral therapy, and reliance on social networks instead of professional counselling.

The article’s argumentation is rather sloppy, but it’s a good overview of some of the relevant issues, and worth reading.

The key issues, I think, are that:

1. Group debriefing only works if the members of the group all had “the same exposure to the same traumatic event.” (Those are the words of Jeffrey Mitchell, the inventor of the current group debriefing process.)

2. Different methods work for different people. Trauma is not like a single infection that can be cured with a single medication. Instead of focusing on general result rates, research needs to focus more on how to determine what method is appropriate for each individual.

3. Not all people are comfortable with psychotherapy. The Director of Counseling at the NYFD said: “You are speaking their language when you talk about alcohol and anger. The simpler you keep the mental-health concepts, the easier it is to engage them.” Steven Hyman, former head of the National Institutes of Mental Health, suggests that trauma victims will be more comfortable opening up to people they’re already close to, such as friends, relatives or clergy.

I think that the more down-to-earth and pragmatic a person is, the less they’re likely to identify with psychiatric speech and concepts. (In Myers-Briggs terms, psychotherapy tends to be N and F; the more S or T a person is, the less likely they are to identify with the psychiatric mindset.) So while any efforts at counseling have to be informed by psychiatric theory, they also have to speak in the language–and level of emotional awareness–of the patient.