Results tagged “psych” from Ψ Dare To Dream...

Time To Change

The stigma about Schizophrenia is huge. Popular media exploits the topic for ratings, not necessarily to better inform the public. Often the results more misinform rather than educate.

A different kind of stigma has a problem within the mental health industry. Up until a couple of decades ago, new practitioners were trained to believe that people with schizophrenia get worse with age, and have no hope for recovery.

Contrary to conventional wisdom, the change paradigm was not the result of new medications. Those meds have been around for 50 years. Recent research has shown that more recent second generation medications have not improved treatment much more than producing fewer side effects. Certainly, medications have done wonders in the treatment of the active symptoms, sometimes called "positive symptoms" of schizophrenia. Hallucinations, delusions, and the disorganized thinking and behaving is effectively treated for many.But the negative symptoms appear to be largely unaffected my the medications themselves.

The real change began with consumers of mental health services become their own advocates and providing peer support. The sufferers themselves discovered that their self-esteem, sense of control, and have become more assertive with mental health providers.

I think that persons with schizophrenia often also suffer from a situational kind of depression. They feel estranged from others, feel helpless to affect their own lives, and hopeless about improvement. This is not surprising given others often avoid relationships with persons with schizophrenia, even mental health providers tend to dismiss much of what they say as "delusional". And until recently, their providers have discouraged any thoughts about improvement or a "normal" life. Applying the principle of recovery leads to significant improvement in these so-called "negative symptoms".

The result was a paradigm change in mental health treatment. Clearly, recovery has been with us for a long time, but you couldn't find it in text books or graduate level courses until a few years ago. The Recovery Movement has revolutionized our knowledge about the long term effects of treatment for schizophrenia.

There is still a long way to go. My colleagues often express a reluctance to counsel people with schizophrenia because of the limited prospects for improvement. I think instead the problem is these therapists have a limited understanding of how to counsel persons with schizophrenia. Progress is indeed possible, but the focus of treatment requires specialized knowledge about psychotherapy with persons with schizophrenia. There is little literature in publication that addresses this topic. However, Silvano Arieti, in his book Interpretations of Schizophrenia, wrote about his approach to psychotherapy with institutionalized persons in the 1950s before the introduction of Thorazine, the first effective medication. See my article for more detail on the topic.

This organization, Time to Change, has published two new short movies, suitable for public service announcements about stigma. Thanks to Dr Deb Serani for the link.

We spend billions on imprisoning the largest proportion of our population than any other nation. Too many of those imprisoned are petty drug offenders. In prison, they some learn how to be more effective criminals and then are turned loose to re-offend. Too many are very young.

Petty drug offenders often need CD treatment, not prison. Many are simply supporting the habit that keeps them from a more productive life. However, petty criminals can become hardened career criminals just from the experience of prison.

These are facts that have been known for many years. The only thing that keeps us from acting on this knowledge is an uneducated electorate. At the recent APA convention, another expert repeats the message.

Image by Rennett Stowe via Flickr

"The current design of prison systems don't work," said criminal justice expert Joel Dvoskin, PhD, of the University of Arizona. "Overly punitive approaches used on violent, angry criminals only provide a breeding ground for more anger and more violence."

Presenting at the American Psychological Association's 117th Annual Convention, Dvoskin discussed his upcoming book, "Applying Social Science to Reduce Violent Offending," which examines why prisons are failing and what needs to change.

"Prison environments are replete with aggressive behaviors, and people learn from watching others acting aggressively to get what they want," Dvoskin said in an interview.

Applying behavior modification and social learning principles can work in corrections, he said. "For example, systematic reinforcement of pro-social behaviors is a powerful and effective way to change behavior, but it has never been used as a cornerstone of corrections," he said.

Also, punishment can be effective in changing behavior, but it only works in the short term and immediately after the unwanted behavior happens, he said. While there is a place for punishment, it should be used in psychologically informed and effective ways. However, punishment should not be one-size-fits-all, Dvoskin said.

"We need to know what may be behind the criminal behavior to know what the best treatment is," he said. "A person who commits crimes when drunk but not when sober is likely suffering from an alcohol problem. Treating the alcohol problem may diminish the criminal behavior.""

Psychology Today - Meaning of Life Blog reports on a research study documents support for a widely held assumption about mental health.

"People who felt most strongly that their lives were meaningful were roughly 40% less likely to die than people who felt most strongly that their lives were meaningless. Regardless of whether people were younger or older (within the range examined in this study), male or female, depressed or not, disabled or in full physical health, high or low income, white or any other race, well-educated or not, living a meaningful, purposeful life was associated with living longer."

Having meaning or purpose in one's life is fundamental to health. Without a reason to live, why would one put up with the difficult parts of life? Feelings of hopeless and helplessness can be successfully fended off by having a purpose and believing one can contribute. A meaningful life is what makes possible recovery from mental or physical illness, chemical dependency, great loss, or virtually any grave setback. Serving one's purpose is what makes it all worthwhile.

Having a meaningful life and peace of mind is what I believe is true happiness. As in Sheryl Crow's lyrics, happiness is "It's not having what you want, it's wanting what you've got." And indeed, it would appear that research supports that concept as well.

A powerful message that I believe is true. Remember the old idea that a dog can smell fear? I think that a clear headed, alert human can sense ill will in another.

Image via Wikipedia

I caught this article at Psychcentral.com, Positive Thoughts Make Things Worse for Poor Self-Esteem . It struck me as a counter-intuitive finding for a research study. I've been helping clients build self-esteem for over 30 years and while positive thoughts is not a short road to better self-esteem, it certainly does work over the long run. I'd estimate that at least six months is required to make significant progress with self-esteem from solely refocusing on the positive, and some people require much more time. Several things jumped at me as I read the article. First of all, Dr. Grohol quoted an article from the The Economist of all places. Both articles stated the research was published in this month's Psychology Research and authored by Wood et al (2009). A review of the past three months of that journal produced no article.

So I went to the old reliable, I googled the lead author, Joanne Wood. I came up with several mentions of her at academic institutions and emailed the author for a reprint. I also found another review of the same article by Ed Yong writer for the Science Blog Not Exactly Rocket Science dated May 15th.

The next day, the article arrived in my email with a short note from the author saying it hadn't been published yet! Apparently, there have been some pre-publication prints floating about likely for publicity purposes. This is one of my pet peeves. Articles submitted to peer reviewed journals are intended to inform the academic community and allow scholarly review and comment. The object of repeated review is to ensure the research is sound and is appropriately interpreted. When it appears first in lay publications, the writers who are not scientists often inadvertently distort the interpretation of the research, as I've noted before. That really didn't happen this time. Both the Psychcentral.com and The Economist got the research mostly right. But Ed Yong did a much better job of explaining the fine points.

This time, it's the researchers that make a subtle but major error in an assumption involving an interpretation of a key measurement. Its subtle because it's endemic in our culture. It seems like everyone assumes that negative feelings are harmful. In this case, Wood et al (2009) found that their subjects who had low self-esteem, immediately reported a lower mood and self-esteem after telling themselves sixteen times they are a "lovable person." Interestingly, persons with high self-esteem report only slight, non-significant improvement in self-esteem.

I decided to do an anecdotal demonstration of the "intervention" for my own understanding. After saying to my self 16 times "I am a loveable person", I felt annoyed, a little silly, embarrassed, and was reminded of quite a few traits which make me not always so lovable. But I can't imagine how this would have any long term effect on my self-esteem either way.

An even bigger problem is one that I talked about before and called it Dust Bowl Empiricism. Researchers are so enamored with their professional activities, they demonstrate their preference for inductive research. Wood et al. reviewed all the relevant research on their topic quite satisfactorily, but then failed to do a sufficient review of related theory. In previous post, I quoted Michael Schermer, a columnist with Scientific American, who eloquently asserted that the really valuable research, the kind of research that can fairly readily be used to educate the public, "higher-order works of science that synthesize and coalesce primary sources into a unifying whole toward the purpose of testing a general theory or answering a grand question." To be fair, few researchers venture into grand theory, perhaps because of the dearth of recent reviews, and perhaps because of the few notable exceptions have been eviscerated by their colleagues for their efforts. Sigmund Freud comes to mind. I have sometimes wondered if psychology's love-hate relationship with Freud resulted in an over-emphasis on induction and de-emphasis of deduction and construct validity.

Wood et al. appears to be testing a specific intervention using Cognitive Behavior Therapy (CBT). CBT purports to change feelings by changing thoughts.

While I prefer more psychodynamic conceptualizations, lets approach this issue of negative feelings from cognitive-behavioral point of view for purposes of demonstrating how relevent theory would aide in the interpretation of research. There is conceivable explanation of low self-esteem and associated negative emotion in the concept of "conditioned emotional response" or CER. A person may learn they are not valuable or important by, for example, an invalidating experience. That invalidating experience is remembered in at least two ways, by the facts of the event and by the associated emotions. According to current understanding of neurophysiology, memories of facts and emotions are kept in different part of the brain, presumably by different methods of storage with different processes of recall. The hippocampus and medial temporal lobe are involved in verbalized memories. Emotional memories involve the amygdala.

Sufficient invalidating experiences may lead to low self-esteem. Whenever a sufferer of low self-esteem remembers an invalidating experience or experiences a new one, she is likely to remember the event and feel the emotion associated with the experience.

In the Wood et al. experiment, the lowered mood and self-esteem are experienced after a validating experience. The subject feels the emotions associated with the original invalidating experience of invalidation perhaps because the positive self-talk controdicts the perception of the subject. Wood et al. makes that point. However, what she misses is that the subject is under going extinction of the conditioned emotional response. The subject is experiencing the emotion without the triggering invalidating experience. According to the theory of Classical Conditioning, repeated exposures to the emotion without the associated invalidation will eventually weaken the conditioning. Perhaps this process is complicated by the fact that the alternative experience, validation, is a close opposite to the conditioning stimulus, triggering a strong emotional response.

In my experience, this triggering of a strong negative emotional response associated with past destructive learning without the presence of the negative stimulus actually quickens the de-conditioning. What this experience amounts to is an abreaction, an emotional re-experiencing of the past event in a supportive and nurturing environment.

One point of the research is well taken. A person with an abysmal self-esteem reading a self-help book will find herself ruminating about how wrong it is that she could be so lovable. Such a person, supported only by herself, is not receiving the necessary nurturing due to her low self-esteem. She is likely re-conditioning the CER with more invalidating self-talk.

The reviews of this article did a fair job of presenting the study. However, there is risk in presenting research to a lay audience. The well written review by Yong had unintended consequences. The comments below the article contained some anquished and angry responses:

"As a person with very low self-esteem who has been encouraged to think positively and love myself throughout my life, I can only thank Joanne Wood for publishing this study. Packaged one-size-fits-all programs promoting the personal pep talk only serve to make those people already in touch with their mediocre side more acutely aware of their non-value within society."

"And when I feel unloved by one person even i feel like no one at all loves me or values me. How can I value myself when i feel like that. and after going thru a marriage where my ex always devalued me and everything i did if he did not approve of it. being abusive, verbally, mentally, emotionally, and physically... and even tho i have come a long way past this experience, it haunts me and i feel lower then dirt. no positive self talk makes me feel better, only makes me feel worse, cuz i figure if i don't actually believe what i am saying or thinking how can it possibly be true?"

Unfortunately, some people with very low self-esteem have been reinforced in their belief that positive thinking can't help. Self-help is best read by the worried well. People with long standing issues with low self-esteem need psychotherapy. Both the authors, Wood et al., and reviewer, Yong, stated this clearly, the other two articles did not. Even so, this knowledge proved harmful to a few. I certainly do not fault the authors for this problem. Yong especially did a great job. One can't ensure everyone reads the entire article or even correctly understands it.

I believe we as professionals who write about mental health have a duty to be as clear and thorough as possible in an attempt to avoid confusion and inadvertant harm. But knowledge is powerful. Sometimes, knowledge mishandled can lead to worsening of symptoms that hopefully brings those in need to help.

Reference: Wood, J., Perunovic, W. Elaine, & Lee, J. (2009). Positive Self-Statements: Power for Some, Peril for Others Psychological Science DOI: 10.1111/j.1467-9280.2009.02370.x

Update 7/15/09: Joanne V. Wood, PhD responds to all the media hype about her research.