Let's Keep the ! in Controversy!

I avoid the “Self Check-Out” at Kroger for two reasons: 1. I have never been able to complete my transaction out without a “Please notify the attendant” malfunction. (Note, yet again, The Great Fallacy of Individualism.) 2. I need the time in the “Check-Out With Other People” lines to read OK!, Star, Us, and, People. Who doesn’t love a good controversy?

Controversy! might as well have been the name for our entire semester, not just tomorrow’s class. Tracking the fault lines of our discipline has provided an exciting and incredibly useful kind of map, one that will be an excellent tool for the rest of graduate school. One thing I’ve learned along the way is that I find some controversies juicier than others.

As far as I’m concerned, whether or not to use empirically supported treatments, scientific evidence, and actuarial judgments is one controversy that should be put to bed. Baker, McFall, and Shoham’s editorial in the Washington Post brings it home when they report that “the practice of psychology—which includes psychotherapy—is akin to medicine as it was practiced a century ago” (italics mine), largely because psychologists fail to collect and scrutinize evidence. Psychologist’s tendency “to use their own insights and experience” to treat patients, instead of using those that have been rigorously scientifically tested, seems to me like obvious malpractice. I’m hoping that there are enough people in the field who agree with me because this is not necessarily an argument I want to have. It’s boring. Look at the question being asked: should you use treatments that are known to help a lot of people when you’re trying to help people? It’s both rhetorical and tautological.

I much prefer questions like, “Can you implant repressed memories?” Or, one I’m working on: “Can teachers indirectly make friends for students?” These are non-obvious questions about people’s experience. They may be counter-intuitive, but they are not counter-logical (the way disagreements about scientific evidence may be). As Jim’s narrative illustrates, the kind of controversies these research questions can spark can be just as incendiary, but I feel these arguments can be more productive, if only after well-designed, well-executed scientific evidence comes to light. I would be absolutely thrilled if, one day, a study of mine evokes as much contempt as Jim’s and Dr. Loftus’ did. I’d know that I was really getting at something deeply ingrained in a culture. I’d much rather argue with somebody who was grappling with a deeply felt conviction, than somebody with an ego so big that they’d claim their own intuition and experience is superior to scientific evidence.

I Love this Week's Readings!

Terrie Moffitt’s Adolescence-Limited and Life-Course-Persistent Antisocial Behavior and Marsha Linehan’s Borderline Personality Disorder have been two of the most lucid, illuminating, inspiring readings of the semester. They are both brilliant figure-ground compositions. Both say a lot (the figure); yet the negative space of the unsaid (the ground) tells just as rich a story. I’m not even talking about “subtext,” here. It’s more like a pulsating “simultext."

Carl Rogers’ unconditional positive regard is the simultext of Marsha Linehan’s article on BPD. My blog a few weeks back scoffed at unconditional positive regard: if psychologists need to operationalize compassion for their clients, I thought, they might be in the wrong profession. After reading Linehan, I embrace unconditional positive regard as both necessary and sufficient. A tell-tale sign of BPD: “The emotional state of both the patients and the therapists seemed to deteriorate when these individuals entered psychotherapy.” Linehan elucidates many mechanisms for maintaining or re-engaging a therapists’ unconditional positive regard for these clients who are so challenging. The first is forthright golden-rule empathy. People with BPD suffer “intense misery;” at another point Linehan likens both their pain and--critically--their basic human innocence, to that of burn victims and cancer patients. This points to another simultext of the article: psychologists have had real contempt for people with BPD. Secondly, the acceptance aspect of Dialectical Behavioral Therapy that is both prerequisite for and mechanism of change is fundamentally Rogerian. Also very Rogerian is Linehan’s emphasis on process over structure. Rogers and Linehan may both agree with the principal of the school for kids with LD I used to teach at: If the process is right, the outcome will be what it needs to be. Of course the “right” processes is often a matter of great debate, but simply (re)locating the emphasis on the process seems much more “right” than not.

[By the way, Borderline Personality is the most misleading term ever. It sounds like these patients are “on the fence” about having a clinical diagnosis or not. In fact what defines Borderline Personality disorder is that individuals don’t hover over a boundary, they continually breach various boundaries. 1. Of life and death (36% of people who meet all 8 DSM criteria for borderline personality disorder are suicidal). 2. Of expected outcomes (by definition, BPD are resistant to treatment). Of client-therapist boundaries (see above discussion of client-therapist emotional states.)]

The simultext of Moffit is the critical importance of etiologies as a framing device or lens. Etiology is like a framing device because of its cropping function; it decides what should be considered as well as what is irrelevant. It’s like a lens because our understanding of one etiological model so easily influences how we evaluate others, making it easy to conflate or invalidate new information that may bear on our model. I entered grad school determined to come out an interventionist. I want to discover the tools for swooping in and changing behavior. More and more, though, I’ve come to realize how critical it is for intervention-oriented psychologists to really refine their understandings of etiologies. A fully realized etiology, like Terrie Moffit’s, does a whole lot of the interventionist’s work. By providing so much evidence about the mechanisms of life-course-persistent antisocial behavior (the kind society really needs to worry about), we interventionists can direct our behavior.

Supermodels

Last week I was overwhelmed by the complexity of depression and how far we are from thoroughly understanding it. This week, on the other hand, I’m excited by how comprehensive and convincing our models for anxiety are. Compared to Coyne’s portrayal of the hyper-dimensional moving target that is depression, anxiety looks like, well, like a series of well-appointed flowcharts. (See Barlow’s figures 1 through 7.) There seems to be relative tranquility about the etiology of anxiety.

Barlow presents us with an “integrated” model. Mineka and Zinbarg lay out the “range of variables (that) can lead to a rich and nuanced understanding of the etiology and course of anxiety disorders.” B and M&Z have different theories as their points of departure, and M&Z address the six major anxiety disorders (and how principles of classical and operative conditioning apply), whereas Barlow basically addresses his “three vulnerabilities” separately. Barlow could have easily stated his same ideas about how life events become a “vulnerability” in the learning terms of M&Z. I don’t think these models are at all at odds.

The beauty of these thorough models (that the authors mention in passing) is their applicability to prevention (anxiety immunization is the coolest idea ever) and intervention. My hunch is that too few therapist apply these sophisticated models to their work with patients.

Why is such a harmoniously integrated model exceptional? (Please correct me if I’m wrong or overstating this.) Why are other areas of psychology still struggling to integrate perspectives in this way? Does that say more about the nature of anxiety or the nature of the discipline of psychology?