Like staring at a Rorschach Inkblot

Two times in the past year, I’ve had to defend the field of psychology to a graduate student of some other persuasion. The first, a philosophy grad student, commented to me politely that psychology was not science because it was never based in hard fact. I quickly replied that actually, we use many physiological measures nowadays that bridge the gap between incredibly subjective judgments and implicit experience or otherwise undetectable behavioral patterns. Actually, we were at a show at Starr Hill, and we were yelling really loud in order to combat the noise from the band, so I probably said something more along the lines of “naw, dude, we do MRI and shit!” And he said something along the lines of “oh, nice.”

The second time this happened, I had been babbling to a good friend, who happened to be a Ph.D candidate in English literature, about the validity of a certain study that I was working on. After I concluded that we should probably do it a certain way for the sake of the scientific method, he replied, “well, it doesn’t matter anyway, because psychology is not real science,” as he smiled back at me, knowing this comment would get me riled up. I turned to him, my eyes got big, and I got so mad that all I could say was “you read books. You. Read. Books. YOU READ BOOKS!! YOU GET TO BE CALLED A DOCTOR AND YOU DON’T EVEN KNOW CPR!”

I enjoyed this week’s readings because I agreed with pretty much everything that was said in them. Garb (1999) very eloquently begged the psychological community to stop using those darn pictures for anything consequential: “Trying to decide whether the Rorschach is valid is like looking at a Rorschach inkblot.” Sechrest & Coan (2002) admirably argue against allowing the field to give people like themselves the power to prescribe medicine. Coan (1997) told an entertaining, yet disturbing, story about what happens when you have no one rooting for you in the field. Lilienfeld (2007), for the sake of identifying potentially harmful treatments, proposed a “centralized databank that is publicly accessible…[to] increase the likelihood that all relevant results from these studies are reported.” (Open-source data sharing! Woo hoo!) And finally, Dawes, Faust & Meehl (1989) informed us that actuarial judgment always (not sometimes, but always) beats clinical judgment. My favorite quote from this article is a disclaimer that should probably come at the beginning of every research article written: “Lacking complete knowledge of the elements that constitute this universe, representativeness cannot be determined precisely” (p. 1670).

But, hmm. What’s the lesson here? Initially, it might seem that theory and researcher bias has, for various reasons, tainted this science in a way that can only be emphasized by the fact that it is almost 2008 and legitimate psychologists are stilling using pictures of inkblots for diagnosis. Blots of ink, on paper, and a client’s reaction to them, are determining the diagnosis for some poor soul sitting at a desk in a cinder block room. I guess my comment to that guy at Starr Hill was naïve: we’re not all using physiological, actuarial, or even the sparse collection of ESTs available when the need arises. Some people are stuck in a time warp, I guess.

Though Coan (1997) shows that this is not correct: theory can and has worked in the past. A mangy kid, playing a few tricks on his family, can take a hunch and produce actual results – even fun, controversial ones. And this makes total sense! Psychology is interesting because it allows us to study passing, fleeting moments of human behavioral paradox, things that catch our eye and make us think “I want to know a little more about that.” Even though people complain about it, and bash it as not a “real science,” they still desperately want to know what it is that we found out from our studies. Even those who distain going to psychologists still seem to not mind being psychoanalyzed every now and again – because it’s fun to know about yourself and know more about humanity as a whole. The English and philosophy fields talk about it, but we actually do it, and we strive to explain why we do it, and why we might do it again and again! I’m not sure what more you could ask for in a science!

“The only people for me are the mad ones.”

There’s something about the borderline personality that I adore. I have a few very close friends that have been officially diagnosed with borderline, usually during a point of hospitalization. These friends of mine are the type that yell and scream and dramatize and love very intensely, and are a thrill to be around. I have clung to them over the years as Kerouac must have clung to Cassidy, desiring to get saturated in moments of pure, intense, fiery life interaction.

But, despite my experience with said personalities, I will not claim to understand them in the least. (And in many ways, that’s part of why I adore them still.) Trouble once came when I began rooming with a good friend at the age of 20. Doctors had been going back and forth about whether she qualified as bipolar or something else, and much of our friendship centered around talking about our feelings and relationships. I credit her for turning me on to feminism and healthy eating, and that was the year that I switched my major from English to psychology, partly because she revealed to me the amazing world of neuropsychology.

But then winter set in, and the apartment began to lose the flare it had previously held. She gradually began to recess into her room and refuse all efforts to get her to go out or experience life. Much to my surprise, she stopped listening to encouraging words, often turning away from me in an air of malice and contempt for anything I had to say. Her room turned into a womb: uncharacteristically warm for the winter, and dark. She would put sweatshirts over her monitor to dim the light, and blankets over the windows so that she never knew what time of day it was. When walking into the apartment during the months of February and March, the charge in the air made you stiff upon entry, and each step inside had the potential to set off an IED. By April, her addiction to cutting herself became as intense as an alcoholic’s addiction to his hidden whiskey bottle.

She was eventually diagnosed as having borderline PD, and I regret to say that she and I are not friends anymore. This is very upsetting to me, as I was quite accepting of her and not at all afraid or shocked by her actions (which seemed designed to be shocking). In many ways, I feel that I failed her. However, my hindsight analysis of this situation, based on Linehan’s (1993) definition of borderline PD and the therapy required to help it, makes me think that I was just not the right person to help her. In truth, based on the transient and silly pejorative basis for such diagnosis as “personality disorders” (see Allison’s brilliant assessment of the ridiculousness of PDs), I’d bet that the chances were more likely than not that, whoever I was, I was not going to be able to help her. Assuming someone with a “personality disorder” wants to be helped, it takes a special person, a special therapist, to work with people in such states of distress. Linehan (1993) proposes DBT, based on Zen principles, but no matter what you call it or how you frame it, I bet Linehan is just great at therapy.

I bet Norman Mailer was high on factor 1.

Moffitt (1993) proposes two distinct pathways for the development of antisocial behavior. The first path, life-course-persistent, begins in early childhood, continues throughout the life, and is probably genetic. The second, adolescent-limited, is a natural, normative reaction that many teens have to the maturity gap that has evolved since the industrial age. Adolescent-limited delinquents are stuck in state of biological maturity without the benefits and cues associated with social maturity. During this maturity-gap, these youths tend to mimic their life-course-persistent counterparts in an effort to cope with the discontinuity of their physical and social age, as the life-course-persistents seem to make their own rules and have it all. These adolescent-limited youths also tend to remit their antisocial behavior once placed in an environment where they have an opportunity to accept responsibility or are given something to lose as a result of antisocial behavior. Moffitt concludes the article by outlining what future research will find, if her theory is correct, while noting that we should distinguish between the two types when studying antisocial behavior in youths.

The theory that Moffitt proposes is intricate and, in many ways, quite beautiful (such as when she likens the mimicking behavior of teenagers to the mimicking behavior of hungry tamarin monkeys, p. 687). However, by restricting her discussion to antisociality as defined by the DSM-IV, Moffitt is missing a huge chunk of the literature that examines covert personality traits versus overt behavioral features of antisociality. In contrast to the DSM’s definition of antisocial personality disorder, the psychopathy literature separates antisocial characteristics (“factor 2”) from interpersonal/affective characteristics (“factor 1”) when making a diagnosis using the Psychopathy Checklist-Revised (Hare, 1990). By further investigating the antisocial behavior factor in contrast to the interpersonal factor, it has been found that the two factors are differentially related to anxiety and fear: greater antisocial features are associated with higher anxiety levels and interpersonal/affective features are associated with low fear levels, but normal anxiety levels (Fowles & Dindo, 2006). Put another way, those who exhibit a need for stimulation, have poor behavioral controls, are impulsive, and break the law repeatedly tend have anxious apprehension about potential future threats, whereas those who are manipulative, pathologically lie, and lack remorse or guilt tend to lack fear, which is can be defined as the activation of the autonomic nervous system in order to deal with imminent threat. My qualm with Moffitt’s (1993) approach to antisocial behavior in youth is that she looked at it in terms of antisocial behavior as a whole, addressing it as a neuropsychological deficit originating in childhood based on the presence of a broad definition of antisocial behavior (p. 680). However, just as she calls for a differentiation of life-course persistent vs. adolescent limited teenagers in addressing pathological antisociality, she needs to differentiate, within the life-course persistent group, between children high on the behavioral versus interpersonal features of the construct. One reason for this is that the interpersonal feature as found in psychopaths is much more robustly related to long-term criminal activity than the behavioral feature alone: of the 80% of incarcerated criminals that qualify for a diagnosis of APD according to the DSM, 20% of those qualify for a diagnosis of psychopathy based on the PCL-R, and that 20% commits 50% of the overall crime (Hare, 1993). Moffitt’s (1993) statistics for this are a bit more dramatic, as she cites an even smaller 5% or 6% of criminals being responsible for 50% of the crime. I’m pretty sure there have been studies linking psychopaths high on the interpersonal factor alone as having committed more crime, but I do not have a book handy to cite this.

I am not sure that Moffitt would entirely disagree with me when it comes to the interpersonal factor, as I just found a more recent article of hers (Viding, Blair, Moffitt, and Plomin, 2005), researching interpersonal callous-unemotional traits in 187 5-to-7-year-old twin pairs. They found that callous-unemotional traits in children are under strong genetic influence but under no environmental influence, compared to antisocial behavior, which is under moderate genetic and environmental influence. This goes along with Moffitt’s (1993) theory, but integrates the interpersonal feature nicely.

The interesting thing about this, for me, is that the defining feature of dangerous criminals is their lack of remorse and their manipulative ways, not their criminal acts. This means that, if put in the wrong environment as a child, that two-faced ass hole you knew in high school could have turned into Jeffrey Dahmer. But he had an attentive mother, so he didn’t. Now he’s just a two-faced ass hole that you want to have thrown in jail, but you can’t, because we have yet to create an “ass-hole personality disorder” in the DSM.

For the eleven of you who read my previous post (which has been removed), I apologize. It was based on nothing scientific or rational, and had no citations or sense. In case you missed it, my last post made grandiose claims like, “fear is the only emotion worth researching.” I might as well have been George W. Bush claiming that global warming does not exist, or Mahmoud Ahmadinejad claiming that there are no homosexuals in Iran. Maybe the fleeting, flamboyant world of the blogosphere went to my head, or maybe it was some sort of subconscious performance art based on that class’s readings about anxious apprehension. Regardless, I promise to never again blog while grumpy.

It's Not Me, It's You.

Three weeks ago, I reluctantly dropped my dog, a Siberian Husky/German Shepherd mix named Cal, off at the local SPCA. Standing at the intake desk with Cal on a leash, I answered various questions regarding Cal’s habits and tendencies. Cal happily sniffed and engaged passers-by and occasionally put his paws up on the counter to peek at the lady behind the desk while I explained how he was a happy, energetic dog, but very complex, very emotional. I had spent the past six months with Cal, and despite his very happy daily attitude, we had gotten in a couple tiffs over food. Dogs can sometimes get very possessive of their resources, to the point where they will growl at you when you bring your hand near their food bowl. Cal had this problem. This was not why I was giving him up, however. I was giving him up because I’m a selfish 24 year old who likes to travel a lot and can’t afford a dog, financially or emotionally. Anyway, when I say “tiffs over food,” what I mean is that Cal would growl when I fed him, at which point I had no choice but to take the bowl away (I had to win the argument), and being that he is about my size, this was a challenge - a couple times, it got quite ugly - but I always won. After I took the bowl, he would be very upset. He wouldn’t continue growling, but he was noticeably angry. He would sulk. He would give me dirty looks. If he could walk and talk, I know he would have probably cussed me out and slammed the door behind him on his way to bed. It would take him about 24 hours to start treating me normal again. He was incredibly joyful and friendly, but he was also the deepest, most complex dog I have ever encountered. I was trying to explain all of this to the lady behind the counter, but could tell by the rate of head nods and “uh huh’s” that she displayed, that maybe I wasn’t getting through. She had probably heard owners being grandiose about their dogs' abilities and quirks before, and I was just one more person ranting on about how "special" their pet is.

Well, it circled back around. This morning, I got a call from the SPCA. They’ve tried breaking him of his “resource guarding,” and it isn’t working. They had tried feeding him with a bowl and he reacted violently – to the point where she did not feel comfortable letting anyone at the SPCA interact with him: he was too scary. My heart sank, to say the least. In my head I was thinking that they should have been hand-feeding him, like I did everyday. I was thinking they should let him interact with dogs and people, like I did everyday, and they should never give him treats, unless he does something amazing, and even then, it can’t be an awesome treat, it has to be lame, because he has to constantly be in need. Feeding him in a bowl was the easy way, and Cal wants it the hard way—he wants to work for everything, and he loves a challenge. But as soon as he gets that sense of entitlement that comes with a neatly packaged bowl of food at his disposal, he says “to hell with the relationship!” and starts growling so you’ll bug off. He has to be trained to need you, all the time, everyday.

In the last two months that I had Cal, he never growled. He sat and laid down on command. He trotted next to me while I went for a run, without the aid of a leash. He can learn, he can be obedient, and he is smart. Too smart, in a way.

But things are not going well at the SPCA. They think he’s part wolf. They say he’s not adoptable. They do not feel comfortable handing him over to anybody. He does not fit in society as-is. He belongs in the wild.

I think of him isolated behind the chain-link walls of a dog run, and sigh.

To me, this situation screams the points in Coyne (1999), and Kendler, Kuhn & Prescott (2004). Cal has an optimal flourishing environment, and a non-optimal one. Regardless of whether his optimal environment is feasible for the typical SPCA adopter to provide, he does have the possibility of flourishing. Everybody does.

Removing the computer from your bedroom gains you 10 points.

Both the model for relapse prevention (Witkiewitz & Marlatt, 2004) and the behavioral approach to insomnia (Bootzin & Epstein, 2000) are about cues. Each approach teaches a client to identify the cues that lead to a certain behavior, and then either embrace or avoid them, depending on the circumstance. They both also address the training of some sort of inner animal, separate from the client’s personal mental experience.

I adore the notion of separating the current experience of the body from the long term goals of the mind. Doing so might reduce the occurrence of attributing uncontrollable thoughts and sensations to one’s own personal faults or actions (e.g., I drank too much and feel guilty about it), possibly preventing a worse cascade of bad behavior (e.g., well, I might as well drink again tonight!). The separation of the two thought processes is mighty powerful as well, helping one to think of Person “A” with a brain as trying to regulate Thing “B,” a headless body, might help one disconnect emotional ties more easily, or at least re-label them with physical labels (e.g., changing “I’m so frustrated about not being able to sleep!” to “My body is a bit over-aroused. I should get up and read a book until my arousal level diminishes.”).

Reading the article on sleep was so beautiful in its self-nurturing applications that it made me want to go buy a massive terry-cloth robe and slippers just so I can look forward to putting them on when I wake up in the morning. Maybe I could buy some candles and take a bubble bath every night before bed as my sleep cue. How nice!

Can you teach it to a rat?

Jacobson et al (2001) and I may or may not have had the same mother. After putting down this article, I had a flashback to a few moments in my growing years, when my mom would follow me around the house as I dashed in between an after-school meeting and crew practice. I would stand there, pulling up a pair of short trou, wolfing down a bowl of cereal, and asking her for a note to skip AP history, while she, not having spoken to me in days due to my busy schedule and getting frustrated that various half-started projects of mine were littering the entryway of the house, would say “Cath, one thing at a time. One. Thing. At. A. Time.” She said this knowing that I had been sleeping four hours a night, that I lived out of my car to save time between meetings and sports, and knowing that when I’m sleep-deprived I get crabby and snap at people (or, snap at her).

Jacobson seems to have come up with the “get your ass up!” method for people that do too much, think too hard, and are also in the midst of major depression. Their methods of emphasizing positive reinforcement, easy, one-step-at-a-time goals, and client-based situational analyzation (or, functional analysis) strike me as major life-lessons and extremely cognitive. However, their behavioral approach is right-on, because it avoids the volatile cognition market of the internalized and distraught.

It’s especially mind-blowing to see the redirection of our readings from looking at higher-order cognitions to more animalistic explanations of mental illness. One might counter these explanations by saying that most people are more complicated than a rat – but are we?

I wanted happiness to be a by-product of a large effect size, but it wasn't.

Reading Engels, Garnefski & Diekstra (1993) was like yawning to even out the air pressure behind one’s eardrums during an assent: after previous readings frustrated and tore at our scientific souls, Engels came along and eased the empirical tension, in a way. They painstakingly ripped apart studies of rational-emotive therapy until their hands bled with the lines they drew between the “masking of [an] experimenter” and “masking with data collection” (p. 1084). And their conclusion? Yes, rational-emotive therapy seems to be more effective than sitting on one’s couch and crying, but this difference is not statistically significant (p. 1086). The climax of the story came when, despite seeming to want to have their article support RET as something worth researching, they were frank about the results of their meta-analysis: “The methodologically more rigorous studies tended to produce moderate-to-low treatment effects," and “Concerning age, social class, and seriousness of disturbance, generalizations from this meta-analysis to clinical practice do not seem to be permitted,” and “no superiority over alternative treatments was found. However…methodological rigor…indeed had a decreasing influence on magnitude of ES" (p. 1088). They have more or less come out to say that, by manipulating the studies to find the good data, they found that the data was significant when the results were not applicable to real life, and the data were not significant when the studies were well-executed.

I believe Engels, and at the same time believe that we have it all wrong. Why are we not studying individual, successful therapists? I won’t go as far as to say that I believe in the dodo effect, but all of these articles have me skeptical of whatever it is we are measuring through therapy research.

But then, after reading Butler, Chapman, Forman & Beck (2006), their meta-analytic support for cognitive-behavioral therapy seemed show most of its strength in the follow-up periods after therapy ceased. Rarely, however, did those follow-up assessments take place after one year post-treatment. But then again, what is the goal? Is the goal concrete, such as a reduction in recidivism (p. 27)? Is the goal happiness in the abstract? I thought about these questions when brainstorming of what to write in this blog entry, and penned down the phrase “Happiness is a by-product of ordered thinking.” Then I crossed out “of ordered thinking,” leaving just “Happiness is a by-product.” Then I realized—there’s no way I came up with this phrase…it seems too familiar. So I googled it—turns out, according to some random, unreliable source called thinkexist.com, two people have said this: Sam Levenson, who said, “Happiness is a by-product. You cannot pursue it by itself,” and William S. Burroughs, who said “Happiness is a byproduct of function, purpose and conflict; those who seek happiness for itself seek victory without war.” This is humorous to me, as William S. Burroughs was completely off his rocker and accidentally shot his wife by having her put an apple on her head and trying to pull a William Tell stunt while high. My guess is that Sam Levenson was equally kooky. But still, the phrase makes total sense.

My point is that psychological stability seems too complicated to address in brief treatments and expect some sort of definitive change to take place in a measurable time period. Therapy is not a pill, and that’s why it works in the long term, for the long term. But works at what - flattening the personality, or accepting a bumpy one?