A quick link for Christmas Day, reviewing a researcher's work on the placebo effect:
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Tuesday, 25 December 2012
Wednesday, 19 December 2012
Happy holidays, everyone.
Time for a short break. I will be taking some time away from the blog (and, hopefully, the computer) over the holidays. My next post will be Tuesday January 8.
Monday, 17 December 2012
Tragedy and Mental Health
In the wake of disasters such as Newtown, Columbine, Polytechnique Montreal, the Portland Mall, and others, the sequence of events has become depressingly predictable.
At the first reports of the events, the news trucks are scrambled as fast as the SWAT teams. Live feeds come in from the site, with excited reporters darting around for scraps of information. If the event is sufficiently “significant” - by which is meant a high enough death toll, the coverage goes into overdrive.
Driving around town doing errands this past Friday, a Canadian station punctuated one of its hourly news broadcasts with the dry observation that a US network had suspended all of its afternoon programming to focus exclusively on the event, just as it might do with the Superbowl.
In the course of the coverage we are treated to reporters scrounging for survivors and, in this case, worried parents, so that we can hear every detail of what they saw. If they saw nothing, they are asked how they feel, and this is reported as breaking news. The father of the shooter in this instance apparently found out from a reporter coming to his home for a reaction shot, and his response was duly recorded in story after story.
The script in these events calls for the shooter or shooters to be identified and then turned into celebrities. Their names and photographs are repeated over and over again until everyone on the street remembers them. In the Newtown tragedy a scrap of blurry archival video showing the boy from the rear was played repeatedly. Or so I’m told. If they were bullied or otherwise felt wronged, their grievances are aired publicly for the entire world to hear. Osama bin Laden himself couldn't get his point of view so widely disseminated.
The possibility that the quest for fame and media coverage may be among the causal factors in these incidents is studiously avoided – although that too would be dissected by the media if they could find their way around the irony.
Next in the sequence is the enlisting of mental health professionals to offer their opinions about an individual they have never met and about whom they know nothing. They pick their way gingerly around the issue, carefully avoiding direct statements that may later be refuted. These are typically given no more than five minutes on screen, as the appearance is an exercise in saying nothing.
The focus then widens. The possibility that the widespread availability of guns may be a problem is briefly considered. As one currently-viral facebook post puts it, “One failed attempt at a shoe bomb and we all take our shoes off at the airport. Thirty-one school shootings since Columbine and no change in our regulation of guns.”
Not entirely true, of course, at least in Canada. Our government has taken decisive action – responding to a badly-implemented gun registration law by cancelling the program altogether and shredding the information they spent millions to collect.
Politics is the art of the possible – you have to respond to moments of opportunity when they arise. So maybe it is not surprising that various groups seize upon tragedies like this to push their agendas.
One of the scripts, which scarcely needs dusting off as it is brought out so regularly, is the need for increased funding for mental health services. Given what I’m about to say, let me be clear: I do think that mental health services are poorly funded in most countries, and what funds are available are even more poorly managed. Let’s take that as a given.
The assumption, however, is that increased mental health funding will result in lower rates of school shootings and other mass killings. With better funding would come better screening of the population. Individuals at risk of perpetrating events such as these would be identified. Treatment would ensue, and tragic outcomes would be averted. The rate of mass killings would decline.
All of this is possible. But I am not aware of any evidence that any of these assumptions is true. If you survey mental health clinicians, many believe these ideas, and they may well be right. Certainly there is little reluctance for anyone to express these beliefs in the media.
What we seldom hear is the converse opinion, which is also held by many people.
Imagine a world in which the funding for mental health programs is doubled or trebled. My own belief is that this would not have any significant impact on the incidence of mass killings.
That may not be a popular idea, and so I suppose I should have strong evidence to back it up. I don’t. In the absence of clear evidence, it is merely an opinion – just as the belief that an army of clinicians could reduce mass killing is an opinion.
I’m not alone in holding this idea, and others have doubtless thought it through better than I have. But here’s my reasoning, such as it is:
With better funding would come better screening of the population. Cadres of new clinicians would have to go looking for clients, and we would institute mass screening of students, disaffected employees, and other citizens. This seems both unlikely and undesirable. I strongly doubt that improved mental health funding would result in more community screening, and if it did there would be an outcry.
Individuals at risk of perpetrating events such as these would be identified. The common refrain after events like these is “he was such a nice, quiet boy; I would never have imagined him doing something like this.” This from friends, family, and neighbours. Later it often emerges that there were signs from facebook postings or other online activity. Mental health workers have no magical ability to divine dangerousness, and have access to considerably less information about the people they see than the person’s own family. We might be able to identify people at somewhat higher risk of perpetrating mass murder by looking at specific variables – like the fact that someone happens to be male – but the resulting number of false positives would make this pointless.
Treatment would ensue. Mental health treatment is almost always voluntary. Most perpetrators do not seem to have seen themselves as mentally ill and so would probably not seek out or cooperate with treatment. The very hostility of their acts suggests a belief that the problem lies outside themselves and that they are justified in their rage. As well, the perpetrators usually seem to be middle-class individuals who would already have access to the mental health system if they chose to seek it out (there may be data on this point, and perhaps data that contradict this observation, but mass shooting does not usually seem to be a crime of the impoverished).
Tragic outcomes would be averted. If treatment was provided, the risk of offending would be eliminated, or at least much lowered. This might be true, though there is scant evidence in support. One argument against is the number of instances in which perpetrators (such as the accused in the Aurora theater shooting) were already in some form of treatment. There is a problem with this, obviously: deeply troubled young men are more likely to be in treatment anyway, and perhaps treatment reduces their likelihood of offending without, unfortunately, eliminating it. But we would still need evidence to claim decisively that mental health services reduce risk at all.
So if we can’t troll through the population, if we can’t really identify risk very well, and we can’t control risk should it be found, it’s hard to see how increased mental health funding will eliminate school shootings.
A colleague of mine once observed that mental health clinicians are the ones who chase after the horse after the barn door has been left open. By this reasoning, we would be no more likely to reduce the incidence of shootings than by increasing the number of emergency trauma surgeons.
Why bother making this point? In times of tragedy, it’s always tempting to go for the easy answers. Let’s just increase mental health funding. And mental health clinicians, all too aware of the gaps in service, are reluctant to contradict anything that might result in a more comprehensive and well-funded system.
But this particular problem may not be caused by the lack of mental health care – not much, at any rate. The real culprits almost certainly lie elsewhere: the availability of guns, the aggrandizement of violence in media and its actual practice in the artificial world of video games, a cultural sense of entitlement and rage. And an obsession with celebrity causing some to seek it in the only way a young, talentless male can manage: by destroying the lives of others. A method that is based not on distortion but on an accurate perception of the consequences of amassing a high body count.
Inevitably, I can be criticized on the same grounds as anyone else who spouts off, sans information, in a public forum. What makes me think I know any more than anyone else? I don't. This is just one more of an avalanche of blog posts by people far removed from the circumstances. The irony isn't lost on me. But frustration makes me point, as others are doing now, at one of the many likely culprits. So let's lighten it up with a quiz question.
Quick, name these celebrities:
- The perpetrator of the Newtown tragedy.
- The Aurora theater killer.
- The Columbine boys.
- The Norwegian extremist who killed teens at an island campout.
- The Montreal Polytechnique shooter.
I won’t reveal the answers, because they have been elevated to the public consciousness more than enough.
But if you came up with any of their names, try Part 2: Name one, just one, of their victims.
Thursday, 13 December 2012
Profession: Iatrogenic Fear of Emotion
|Some fear is normal.|
One of my interests in recent years has been the negative impacts of the mental health system. Although mental health services are intended to contribute toward mental health, unexamined assumptions often seem to result in unintended harm. A friend and colleague of mine once remarked that he felt the majority of his time was spent trying to undo the damage of previous mental health care.
In my last post I touched on one aspect of this issue – the belief amongst practitioners that having the best of intentions for our clients will contribute to better outcome.
It certainly does help to hold the best interests of our clients uppermost in mind. But we can’t use our intentions as a substitute for knowledge, training, an assessment of what the client really wants to achieve, or good old uncomfortable self-doubt. We should always be questioning what we are doing, rather than resting easy in the confidence that our good intentions will inevitably lead in a positive direction.
I remember a student at one point debating the relative merits of psychotherapy and pharmacotherapy and remarking “well, at least we don’t do any harm.” The assumption was that at worst psychotherapy will be ineffective, a null outcome, and holds the potential for significant gain. It took some effort to convince him that in fact psychotherapy, practiced incompetently, can be extremely damaging – I gave him some of the examples mentioned last week.
Treating Emotions by Making Them Scary
Clients often come to therapy because they are experiencing troubling emotional states: anxiety, depression, anger, guilt, shame, or what have you. They don’t like the discomfort (or the horror) and this is absolutely understandable.
In therapy we work with the person to develop strategies that will enable them to reduce the magnitude of these difficult emotions. By gently venturing into the situations that frighten us, for example, we can reduce our fear in the long run. By pushing past the inertia that depression brings and reclaiming our lives, we can reduce depressive despair. And eventually what was a disabling state becomes a manageable and even helpful guide.
But there can be an unintentional message of therapy for difficult emotional states: “These are dangerous feelings and you are quite right to be frightened of them – we need to do all we can to stamp them out.”
On one level, this makes sense. Example: depression, left unchecked, may lead to job loss, relationship breakdown, and suicidality.
What is the impact, though, of labeling an emotional state as a threat – or as a disease? This removes any of the existing signal value the emotion may have. It no longer means “Hmm, working 16 hours a day at a job I hate may not be sustainable” and becomes “I’m mentally ill.”
Further, by frantically steering the client away from the emotion, we emphasize that it is something to be feared. If fear is already the problem then we have just added to it.
An extreme example of this comes from recent announcements about the upcoming revision to the diagnostic manual used by most of North America, the DSM. DSM5 will remove an exclusion to depression diagnosis for individuals who are recently bereaved.
It’s easy to see the reasoning for this. Bereavement is an extreme emotional state that can be temporarily disabling in intensity. There is no requirement that the origin of a state be mysterious in order to be classed as a disorder. For example, we can diagnose caffeine intoxication even though it’s obvious why a person is experiencing it: they just drank a gallon of coffee. A bereaved person recently lost someone profoundly important to them, and as a result they are now experiencing symptoms very similar to clinical depression. No surprise.
But this makes normal grief a mental disorder. Rather than being a difficult, challenging, but normal-range life experience, grief becomes a mental illness. And paradoxically, the failure to experience any grief when a person close to us dies is a non-disorder. The abnormal is normal, and the normal has been classed as abnormal – and therefore subject to intervention.
Do We Create the Problems We Treat?
The concern is that by labeling an increasing number of normal human experiences as mental disorders, or by declaring them treatable, we are narrowing the range of human emotion that our society deems acceptable. The former highway of feeling that we may have been permitted begins to resemble a narrow sidewalk, or a tightrope. Anyone outside these shrinking limits becomes disordered and in need of a pill or a Viennese couch.
I now frequently see people who have become discouraged during a difficult part of their lives. They have been told that the discouragement or lethargy they experience is a disorder, a disease of the mind. In some cases, they have been informed that they have a brain disease that will need medical treatment for the rest of their lives. Apart from being simply incorrect, this well-intentioned diagnosis can be profoundly damaging.
The mental health industry’s claim to ever-greater tracts of normal emotional territory seems likely to have effects beyond the consulting room. The taint leaks into the surrounding culture. When we leap forward and lecture on the emotional damage caused by natural disasters and improper diet, when we help create magazine quizzes (“Could YOU have social phobia?”), when we participate in the proliferation of diagnostic categories, we may be damaging the society we live in.
Although well-intentioned, our efforts may create more misery than they relieve.
Tuesday, 4 December 2012
Process: The Fallacy of Good Intentions
|Nice idea, bad results.|
I cautioned her that having a desire to help on the one hand, and actually helping on the other, are two separate things. But I realized afterwards that I was holding back in an effort to play nice. The truth is, I think that a belief in the power of good intentions is one of the most damaging elements of our field.
Going beyond what the student said, or perhaps intended, the idea seems to be that if one has a pure heart and wishes for the best interests of a client, then one will naturally choose actions and strategies that will lead in that direction. At minimum, the clinician will do no harm.
The type of therapy I do often involves working with a person to discover their underlying assumptions (about themselves, others, the world) for problematic ideas that might be leading them astray. The same idea can be applied to governments, cultures, and professions, including the profession of psychotherapy.
The belief in the benevolence of good intentions is a good example. It distorts by encouraging us to believe in what we are doing, and to lower our guard against potential harm. It relaxes the need for research evidence. After all, if our intent is positive, then we should at least do some good, shouldn’t we?
The field of mental health has unquestionably damaged a great many people over its history. The examples we hear about most are those in which the practitioner used the client for his or her own ends: sexual gratification, financial gain, a sense of power, or what have you.
But imagine that we could take all of the negative impacts that we have had and sort them into two categories: the product of bad intentions, and the product of good intentions. I believe that the damages caused by good intentions would easily dwarf those caused by evil or self-involved clinicians. Entire areas of practice would fall into the nice-try-bad-outcome category. Some examples:
- The widespread use of lobotomy in past decades. It was believed that simply inserting a metal paddle into the prefrontal cortex and destroying it would result in better mental health. “I know it’s part of the brain, but we don’t really need it.” Egas Moniz was awarded the Nobel Prize for medicine in 1949 for this effort.
- The near-universal implementation of critical incident stress debriefing, which appears to increase rather than decrease the likelihood of lasting post-traumatic effects. I took this training myself and felt a vague regret at never having the chance to use it - until I saw the data coming out on the effects.
- The practice of putting individuals suffering subclinical depression on antidepressant medication, despite the absence of research evidence supporting the efficacy of these medications for this level of symptomatology (a recent study in British Columbia revealed that 20% of women were written a prescription for an antidepressant in one year alone).
- The practice of so-called “reparative therapy” to turn gay men and lesbians into heterosexuals. This never seemed to work, damaged the lives of those so treated, and resulted in the leaders of the exgay organizations regularly coming out and denouncing their former efforts. (This practice was no more “effective,” it seems, than the former strategies of psychiatric hospitalization, electroconvulsive therapy, or, yes, lobotomy.) Yes, I know: This is more the bad-goal-worse-outcome sort of practice, but the practitioners' belief in the goals of their work helps it to fit.
- The therapeutic fad of the 1980s and 1990s of taking vague symptoms of distress as indicators that clients had been abused by satanic cults. At its height, practitioners claimed (sans evidence) that thousands of people were being killed each year in these rituals. They weren’t, but thousands upon thousands of clients were being damaged by well-intentioned but gullible practitioners who jumped on the bandwagon.
It would be easy to go on. In every case, the intention was benevolent – cure people, prevent dysfunction, control illness, or secure a better seat in heaven. The means were promoted by well-intentioned people who genuinely believed that they were doing something positive. The results were disastrous. One can only wonder whether if the people involved believed just a little less in themselves and in the power of their good intentions, perhaps fewer people’s lives would have been ruined.
I’d like to see the belief in good intentions dragged out into the open – preferably in training programs – and subjected to the critical scrutiny it deserves. Like other distorted beliefs – and like vampires – the strong light of day might cause it to wither away.
And good riddance.
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