ShrinkWrapped

Social Science Mis-Reporting and the Value of Skepticism

[Update at the end]

On Monday, the Toronto Star printed an article which delighted liberals and lit up the conservative blogosphere with indignation.  In the article, How to spot a baby conservative, Kurt Kleiner reports on a study in the Journal of Research Into Personality  which purports to show that:

Remember the whiny, insecure kid in nursery school, the one who always thought everyone was out to get him, and was always running to the teacher with complaints? Chances are he grew up to be a conservative.

At least, he did if he was one of 95 kids from the Berkeley area that social scientists have been tracking for the last 20 years. The confident, resilient, self-reliant kids mostly grew up to be liberals.

Apparently, Jack Block and his wife and fellow professor Jeanne Block (now deceased) have been following approximately 100 young people from nursery school to the present as part of a general study of personality.  Unfortunately there is no link to the original article and I could not find the Journal of Research Into Personality on-line.  As I have stated in the past, newspaper reports of scientific articles that do not link to the original article are highly suspect and should never be considered valid or reliabe without extensive clarifying information.  Reading the entire article brings to mind Wolfgang Pauli's famous quote:

This isn't right. This isn't even wrong.

Bear with me a bit and allow me to elucidate.

On Clients & Patients: Part V

[The earlier posts in this series can be found at Part I, Part II, Part III, and Part IV.]

As I pointed out in my first posts in this series, when Doctors are turned into providers, they are reduced to technicians.  At the same time, when patients are turned into clients, or the more execrable "consumers", their relationship to their Doctors shifts into a potential, and all too  often real, adversarial relationship.   Furthermore, by neglecting or denying the fact that people in pain tend to regress, the change denies the treating professionals the single most powerful weapon in their armamentarium.

All psychotherapy is built upon Sigmund Freud's recognition that the contents of the mind are predominantly unavailable to the conscious mind, and the unconscious is the source of most of our psychological difficulties.  The idea that our unconscious mind should be so powerful and determinative of our behavior is now being confirmed by the Neuroscientists but is always a disquieting observation.  Everyone wants to believe their behavior is based on rationality, yet the existence of a dynamic unconscious underscores how little we really understand about our own inner workings.   

Those Psychiatrists, Psychologists, Social Workers, among others, who study and train in the practice of Psychotherapy learn that the most effective agent of change in their patients is through the transference; when early relationships that have been problematic for the person are re-evoked and repeated within the therapy,  the patient is given a second chance to work through the conflicts that began in the past and continue to cause problems in the present. 

Not every problem requires the most intensive work, but all problems addressed in therapy will rest upon some usage and understanding of the state of the transference relationship to the therapist. 

The change in therapy of patients into clients and Doctors into providers began for noble reasons.

Psychoanalysis and "An Army of Davids"

I have just finished An Army of Davids and beyond the fact that it is an excellent read, brimming with provocative ideas, there is a deep current which flows through the book and connects it to larger historical and cultural trends.  An Army of Davids is all about freedom, in the purest and best meanings of the word.    Glenn's overt premise is that the accelerating pace of change in technology has given individuals power and freedom to act that has never been seen before.  Where it once required a newsroom with all their resources to gather information and package it for the reading and viewing public, now it only requires a readily affordable computer, an on-line connection, and a digital camera.  An individual can now do what it took a large enterprise to do in the recent past.   

Man's long slog toward freedom is now accelerating in unimaginable ways. 

From the moment the first inhabitants of the planet discovered agriculture and the first towns and villages sprang up, human beings were faced with a brand new experience; for the first time there was enough "wealth" to support a class of people who were not primarily involved in subsistence.  This is what allowed some early geniuses to invent the first tools and begin the development of technology.

We are now living through a time of such profound change that anyone can become free from the constraints of necessity.  While there are positives and negatives to so many people acquiring such power, on balance I think we will find a way for the "good guys" to outpace the "bad guys" though there are likely to be some harrowing times before we can all relax a bit.

How does Psychoanalysis fit into this picture?

SW's Top 10

Welcome to the fourth weekly* installment of ShrinkWrapped's Top 10.  Out of hundreds of posts, these caught my attention and deserve your perusal.

1) Kobayashi Maru has been on a major roll lately and has written a plethora of excellent posts in the last two weeks.  In Fear, Bullies and Head-Fakes, he makes a point that too many seem to have trouble grasping.  It is a sad commentary that this needs frequent repeating:

Ignoring the bully is one reaction that sounds like it ought to be effective but isn't. Denial is not the opposite of fear but a desperate (and ultimately futile) attempt to hide it. True bullies can sense denial for what it is: feigned strength with nothing to back it up. The high school class victim who too studiously ignores his tormentor (e.g., on his mother's advice) is just as obviously a ripe target as the one that cowers visibly in fear.

The only language that bullies know is power.

I will leave it to you to figure out who the bullies are, but for those who are puzzled, KM clarifies that we are just now Waking Up to a Three Decade War.

2) Although the Oscars are now quickly receding into the dim recesses of the memory sink, James D. Hudnall offers the last word on the subject in Hypocrisy Deserves an Oscar.

3) Continuing on the theme, Armed and Dangerous offers some suggestions to Hollywood for movies that people would actually want to go see If Hollywood Were Really Brave.

4) If the past is prologue, we have been warned.  Norman Lebrecht offers a painful personal reaction to The Shame of La Belle France, a novel that looks with a fierce eye at the "glorious French" during their time of struggle.  The French have carefully nurtured the myth of their subjugation under the boot heels of the Nazis; the story of their collaboration in the destruction of the Jews has been relatively hidden but there were people watching: 

The Council Has Spoken!

This week the voting was much closer than usual in both the Council and non-Council categories, indicating that the quality of all the posts nominated was quite stellar. 

Among Council posts, Dymphna at Gates of Vienna penned a new and updated chapter in the battle of the sexes, King Solomon and the Roe-Men, and was rewarded with a first place verdict by the Council.   Second place went to The Glittering Eye who explains Why the Iranians aren’t deterred.

Among the non-Council posts, the NHS Blog Doctor won with his post, The Crippen Diaries (Week 11) .  This post should be required reading for anyone who tells you we need a national health service in America.   Middlebrow pointed out Why George Bush Will Be Important for Decades and for his efforts was rewarded with second pace.

As always, all the nominees can be found at The Watcher of Weasels and all are rewarding reading.

On Clients & Patients: Part IV

This may seem to be a bit of a digression but has important relevance to the topics I have been addressing in this series. 

(Earlier posts in the series can be found at Part I, Part II, Part III)

The New York Times has a story on the front page of their web site on the misuse of Psychiatry to punish dissidents in China.  Joseph Kahn reports in Sane Chinese Put in Asylum, Doctors Find that the Chinese have taken the old Soviet practice of pathologizing dissent to a significantly higher level:

Dutch psychiatrists have determined that a prominent Chinese dissident who spent 13 years in a police-run psychiatric institution in Beijing did not have mental problems that would justify his incarceration, two human rights groups said Thursday.

And:

The authorities determined that he had "delusions of grandeur, litigation mania and conspicuously enhanced pathological will," which Western human rights groups say are diagnoses that officials have used to lock up troublesome dissidents who have not broken any laws.

After his release in 2005, Mr. Wang described widespread abuses in the mental asylum, known as the Beijing Ankang. He said he had lived in cells with psychotically disturbed inmates convicted of murder and was forced to swallow drugs to blunt his will. He also said the staff members had used electrified acupuncture needles to punish patients while other inmates were made to watch.

The politicization of Medicine and Psychiatry have an unfortunate pedigree.  The Nazis were famous for co-opting Doctors to their ideological purposes and did experiments on concentration camp prisoners that were indistinguishable from torture.  The ethical dilemma of using some of their research data to save lives has never really been resolved, though one could argue that it is a fitting tribute to the victims that their pain and suffering has saved the lives of many innocent people. 

On Clients & Patients: Part III

In the first two posts in this series, Part I and Part II, I tried to show that the change from patient to client or consumer is meaningful on many levels and has systemic consequences.  I pointed out, with the help of several commenters, that the most salient difference between a client or consumer and a patient is that patients come to Doctors when they are in pain and distress.  This makes all the difference.

When a person is in pain, they regress from their typical level of functioning to an earlier, psychologically less mature level of functioning. 

A couple of illustrations might help clarify how this works.  Consider a young child, a 5 year old, running around the house.  He is carrying on his typical 5 year old activity, without a care in the world, with no need for close supervision or much more than an occasional moment to "touch base" with his Mother.  Now imagine that child tripping and skinning his knee; what happens next?  There is the initial shock that the previously benign world has suddenly risen up and struck him; if there is blood, there is the additional anxiety that such bodily leakage always evokes in young children whose grasp of inside and outside is not as solid as it will be later in development.  Tears and wailing ensue; he wants his Mommy.  The previously robust youngster, reveling in his musculature and his movement, enjoying the freedom of the young, has instantly regressed to a needy, frightened baby who needs to be comforted and held by his mommy; only her (or her "stand-in" replacement's) kisses and reassurances can restore him to his previous level of functioning.  A kiss, a band aid (often necessary even when there is no blood), and a short time later, the child is a 5 year old dynamo once again.

Now consider an adult, a grown man, making a living, functioning in the world.  Consider what happens to so many grown men when they have a cold.

Partisans and Rationality

The Anchoress today linked to a column by Dick Meyer, Is This Column Futile?, in which Meyer reports on recent research purporting to show that political partisans are so emotionally invested in their politics that they lose the ability to reason.  Although I cannot comment on the original research (there is no link to it in the article) I can suggest some points for consideration:

When 30 self-described partisans were presented with contradictory quotes about the candidates (President Bush supporting, then denouncing Ken Lay; Sen. John Kerry supporting, then denouncing a Social Security overhaul), it was the portions of the brain that process emotion, not rational thinking, that became active. "The thinking caps went off and the feeling caps went on," is how Westen put it to me.

Normally, Westen says, a brain faced with contradictory information will fire up the zones where reason or rational thought happens. The 30 partisans in this study were presented with contradictory quotes from Bush and Kerry, but also from Hank Aaron, Tom Hanks and the writer William Styron. They processed the information about the non-politicians with the reasoning centers of the brain. It was politics that short-circuited them. ("This is your brain; this is your brain on politics.")

Meyer is pessimistic, though tries to find some light in the darkness:

This is not evidence that America is becoming more polarized or that we are fighting a culture war. While it may be evidence that the numbers of extremists are increasing slightly, and that their extremism and intolerance is increasing, it is not evidence that the huge, moderate middle — that part of the population able to process political information with cold reason — is substantially shrinking or becoming more bitterly divided and less tolerant.

Three points: First of all, there is really nothing new in this report; second, it is probably an oversimplification which fails to shed much like on the ways in which deeply held beliefs and feelings affect our reasoning capacity; and third, a short review of multiple determination and compromise formation might be in order.

On Clients & Patients: Part II

This series was triggered by a post at Dr. Helen about a bit of Politically Correct behavior by the American Psychological Association.  The overt topic had to do with the APA refusing to accredit a conference concerning therapy designed to re-orient homosexuals who were unhappy with their orientation, to heterosexuality.  I share Dr. Helen's skepticism that such changes can be brought about (and would point out that there is no single entity known as homosexuality; just as there are a myriad of characterological and constitutional determinants that shape one's heterosexuality, the same is true of homosexuality.)  However, my interest was stirred by her causal comment:

Personally, I'm skeptical about turning gay people straight. But shouldn't the client be the one to choose, not the APA? [Emphasis mine-SW]

The use of "client" in this setting, a usage that is ubiquitous in the mental health arena, has important implications, the more so because I do not think it has ever really been systematically explored.  Yesterday, two commenters pointed toward the distinction between Patients, Clients, and "Consumers".

sigmund, carl and alfred wrote about laser eye surgery, which over the last few years has gone from a sophisticated medical procedure costing upwards of $2500 per eye to as little as $250.  Dymphna commented on the odious nature of terming patients "consumers" and as she is wont to do, made a humorous and subversive suggestion that therapeutic relationships involve more than a simple exchange of money for services. 

This morning,  EssEm added some comments that get close to the heart of the problem, starting with etymology:

"Patient" comes from "suffer". It is a constant reminder to me that what brings people to my door is their suffering, and that it is my role (and responsibility) to help them find its meaning.

All the comments are illustrative and worth a closer look.  S,C & A's provides us with an excellent starting point.  He suggested that competition and a free market has allowed the price of laser eye surgery to come down to such an affordable level that a once rare procedure has become extremely common and available.  His implicit point was even more important for this discussion. 

First, a little history is in order.  I have worn glasses since ~6th grade and have always wished that I could see clearly without them.  When I first heard of Radial keratotomy, I was intrigued but reasoned that it would be quite some time before the procedure was found to be safe enough for general use.  The procedure, which had its roots in the late 1800's, had a brief popularity in Japan in the mid-1950's, and flourished in Russia in the late 1960's, involved making numerous small incisions in the cornea which, when they healed, subtly shifted the curve of the cornea allowing for improved vision.  The idea of allowing multiple, tiny cuts to be made in my eye, with uncertain assurances of success and greater uncertainties about long term effects, was enough to dissuade me from the procedure, despite how much I was looking forward to getting rid of my glasses.  By the 1990's, American surgeons began to use lasers to more carefully and precisely re-shape the cornea to achieve much better results than the original Russian procedure. 

On Clients & Patients: Part I

Shortly after I earned my Medical degree and started to practice Psychiatry and Psychoanalysis, patients morphed into "clients."  This was a change that grew out of a laudable move to "empower" people, to help them be more in charge of their health and welfare, and to equalize the power relationship between those who were now to be referred to as "Providers" and those who were the "Consumers" of health care.  I have always been uncomfortable with the shift, but at least in the New York Mental Health arena, it was one of those Politically Correct ways of speaking that quickly became ubiquitous and rarely examined.  I almost never use (or used) the terms myself; patients remained patients while "clients" and "consumers" seemed to be slightly unserious designations for people who came to us in distress.  However, as with so many changes that have occurred without much resistance or thought, there are more subtle ways in which such re-naming has damaged and continues to damage our health care system and our patients. 

I will try to show who benefits from this change, who loses and why, and a possible way to arrive at a  synthesis in which Doctors and patients can both benefit.  My focus is on the field of Mental Health, though much of my commentary is applicable to the overall field of Medicine.

First, some context for the change:

In the late 1960's, where so much of our current cultural pathology first took root, all hierarchies, all authority, and all power relationships were to be opposed in the name of equality.