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Thursday, March 14, 2024

The Pervasive Weaknesses of Psychotherapy Studies


A psychiatrist with Intense, bulging eyes by C. Josef, CC Attributions 4.0

 

In my last post, I mentioned that the research into both psychotherapy outcomes and personality disorders is extremely weak, and even that characterization may even be giving it too much credit. Extensive clinical experience has been dismissed as “anecdotal,” even when therapists see the same things over and over again and their observations are confirmed by many other therapists who actually look at the same phenomena.

The irony here is that almost ALL of the “research” data in these two areas is a collection of anecdotes, since they are entirely based on patient self-report or the experimenters’ personal observations – all of which are subject to significant bias. We cannot read minds and people act and lie a lot, and a lot of other influences on the “data” are extant and unknown to the researchers.

Most psychotherapy outcome studies are characterized by frequent patient drop-outs and by the fact that a significant portion of the study subjects do not respond to the treatment being offered. And outcome measures in these studies are typically the relief of symptoms, not changes in the patient’s abilities to love, work, and play successfully. And the subjects are rarely followed up for a significant period of time to see if any results that are attained last. A significant portion of the study “gains” are often lost after a year or so.

There are over 200 different models for understanding psychopathology and doing psychotherapy, although most are variations of the five major models: psychodynamic, cognitive, behavioral, affect focused, and family systems. Most therapists borrow techniques from schools other than the one they were trained  in.

When results from several different studies using different schools are compared, most tend to come out with about the same success rates. In the beginning of a movement to try to integrate the different schools, this was known jokingly as the Dodo Bird verdict (after a character in Alice in Wonderland) – all have won and all must have prizes. And when two schools are compared in a single study, the school of person who is the lead author of the study comes out the winner in 85% of them (an allegiance effect). Bias, anyone?

Even then, when a certain percentage of the study subjects did respond to the “inferior” treatment, we don’t know whether or not they would have done well in the “better” treatment. Or if those who did not respond to the “better” one would have responded to the other treatment.

Over the years I have posted critiques of the “research” and in this post will summarize a bunch more of the points I made. If there is a whole post about them, I’ll include a link to the original.

A big one I mentioned in the last post: when a school of therapy is evaluated, the individual interventions which comprise them (of which there are quite a few) usually are not, so we don’t know which of them worked and which of them did not or were even counterproductive. Responses to the individual interventions are important to know about because, despite the use of treatment manuals supposedly insuring that all therapists in a study using a specific school are doing the same things, this is not possible. Subjects all respond differently to a given intervention. Therapists have to pick and choose which intervention will be used next. Also differing - with significant impact - is the way the intervention is presented: phrasing, body language, tone of voice etc.

Another major study weakness: Those that try to apportion causation of psychological behavioral syndromes to genetic vs. environmental influences use studies of twins raised apart. This type of study routinely over-estimates genetic contributions by assuming parents treat all their children alike, which is way off. Furthermore, they are looking at the end result of gene and environmental interaction (phenotype, not genotype) without any way to know how much of a given finding to apportion to each of them.

Most psychotherapy outcome studies exclude patients with more than one disorder, although a high percentage of patients have co-morbid affective and anxiety disorders as well as more than one personality disorder. The therapy will of course look more effective if you include only the easiest patients.

In studies of psychiatric symptoms which may occur in response to stress, reactions are evaluated without any reference to what the actual stresses were to which the subjects were responding. 

Confusion between correlation and causation is illustrated in such studies as those that attempt to determine the causes or the results of drug abuse. For example: Does marijuana cause poor school performance or the other way around - or is there actually a third factor which leads to both of them?

Differences in brain area size and functioning between different groups on fMRI scans are automatically interpreted as abnormalities. In fact, most differences are due to normal neural plasticity in response to changes in the environment.

In studying  the nature of the relationship between parents and children, No one can  precisely measure the nature of the relationship. These relationships are not constants but vary across time and situational contexts. Parents might be good disciplinarians when it comes to providing children with adequate curfews, for example, but terrible at allowing them to stay up all hours of the night. Furthermore, the disciplinary practices certainly change over time as the children get older. Second, how does a study even attempt to measure the tone of parenting practices? Third, oftentimes studies are based on parent self report. If a mother were abusive or inconsistent, how likely do these authors think she would admit to it, even if she were very self-aware, which obviously many people are not.

In some Cognitive Behavioral Therapy outcome sudies, therapy  is at times compared with "treatment as usual" —letting subjects get whatever other treatments outside of the study treatment that they chose to have, allowing good therapists and bad therapists, and good therapies and bad therapies, to essentially cancel each other out. Even so, the sizes of treatment effects are only small to moderate.  “Response” just meant there was some significant improvement in symptoms, not that the symptoms of the disorders actually went away. Rates for actual remission from the disorders were even smaller. A considerable proportion of study patients do not sufficiently benefit from CBT.

In epidemiological research into environmental risk factors for various psychiatric disorders, most studies try to measure the effect of a single environmental exposure on a single outcome—something that rarely exists in the real world. Individuals are exposed to environmental elements as they accumulate over time, so that one single exposure usually means very little. Exposure also is “dynamic, interactive, and intertwined" with various other domains including those internal to individuals, what individuals do within various contexts, and the external environment itself—which is constantly changing. Last but not least, each individual attributes a different, and sometimes changing, psychological meaning to everything that happens to them.

The difference between “cannot” and “do not:” Study are often characterized by lack of attention to subject motivation, and ignorance of the concept of “false self.” In one study, high-psychopathy participants showed atypical, significantly reduced neural responses in the brain on an fMRI to negatively-toned pictures under passive viewing conditions. However, this effect seemed to disappear when the subjects were instructed to try to maximize their naturally occurring emotional reactions to these same pictures!

Researchers mistake a high index of suspicion for an “inability” to correctly read the mental states of others.

Studies show that changing a parent’s behavior towards BPD children can make those with BPD better—but seem to ignore the possibility that their behavior apparently helped cause the disorder in the first place.

Thursday, February 22, 2024

When Children Kill Their Parents


According to CBS News, most offspring who kill their parents are adult children, meaning they are over 18 years of age. Over the 32-year period examined, the number of juvenile parricide offenders was substantially lower. On the average, juveniles killed 31 fathers and 18 mothers per year. The reverse is more common: according to FBI statistics, an average of about 450 children of all ages yearly are killed by their own parents. Parents were responsible for 61% of child murders under the age of five.

The fact that young children or older adult children kill their own parents seems to run counter to one of the themes of this blog: that a lot of behavior problems and self-destructive patterns are caused by the residue of kin selection, the tendency of people to put their kin and ethic group’s interests above their own, and in certain circumstances be willing to sacrifice themselves. Even die for them. If this is really the case, and I’ve been witnessing self sacrifice for decades in my psychotherapy patient population, how can we account for children killing parents?

I must admit I do not know for certain, since I have never had anyone who killed a parent in psychotherapy with me. However, based on my theory, I believe the main reason may have to do with another concept I’ve written about: Hatefulness as a gift of love. In some cases, parents hate themselves so much and think their children are so much better off without them - even if the child ends up in jail - that they act hatefully to such an extent that they kind of give off the message “kill me.” 

Another reason was illustrated in a case I am about to discuss: A parent who wants to murder a spouse may appear to be so selfish as to have their child take the rap for killing that person—thinking that the child would not have to go to jail due to being so young.

In almost all cases, kids who kill parents are victims of severe abuse, as in the cases to be discussed. But severe abuse alone is clearly not enough to induce a kid to do something like that, since the number of cases of severe child abuse massively exceeds the number of such killings. Most children who are abused do not even tell on their parents, let alone kill one of them. As little kids, they often think being beaten is normal, and worry more about their parents’ mental health than their own. So it has to be abuse plus something else. In one of the two cases to be discussed, it was a direct suggestion.

As one piece of evidence that the theory of self-sacrifice is correct even in these cases, one of the persons about to be discussed (Ms. Bailey) says herself in her book: “It is innate in us to want to protect the only thing we know, and even through abuse and neglect we still seek to protect the very ones who inflict such pain.”

Two cases  have been in the media lately: The first was featured on an A&E TV documentary called The Prison Confessions of Gypsy Rose Blanchard. When she was in her early twenties, she induced an angry and easily manipulated boy  to kill her own mother. Afterwards, she was imprisoned for almost 10 years before being paroled.,The actual killer is still in prison. 

The second is in a book called My Mother’s Soldier, written by a woman named Mary Elizabeth Bailey. When she was only 11 years old, her mother induced her to shoot and kill her highly abusive stepfather. In that case, she was afterwards whisked away to foster care while her mother went to jail, just as the mother must have suspected would happen.

Both of these women relate horrifying tales of severe abuse by parental figures, while Ms. Bailey was also severely neglected.

Blanchard was a victim of Munchausen by proxy, where her mother faked illnesses in her as well as disabilities in order to get money. People, including supposedly much of her mother’s family, didn’t think she was able to walk, since she was always in a wheelchair. She was subjected to surgeries and medications she did not need. Apparently mom was really good at faking this stuff in her with doctors, and the girl willingly went along with it. At one point mom insisted the girl had a fear of eating, and a stomach tube was surgically inserted in her. She was in the hospital for six months with it.

The two of them moved from place to place. The mother would not let her go to school  or have any friends, so they were each other’s only major relationship in life for years. The child felt so stymied that she recalled her first day in prison as a happy time. For the first time in her life - even in that environment - she felt “free.”

In the Bailey case, the murderous child had  been sexually abused by her grandfather – who of course denied it when interviewed and who theorized quickly that Mary was trying to shift the blame for the murder on to him. But how on earth had he brought up a daughter who would do such terrible things to her own daughter? By comparison, Mom made him look like an ideal parent.

Unlike with the grandfather, Bailey idealized her grandmother. This is understandable since Grandma was the only family member who treated her with love in one-to-interactions, and frequently took her under her care when the mother wanted to go out and party. On the other hand, grandma had also been the one who raised the incredibly irresponsible mother who had dropped out of school very early, ran wild, had sex somewhat indiscriminately with multiple partners even while married to an insecure, violent alcoholic (who probably was doing the same thing) who frequently beat her up. And Grandma often returned Mary to the mother’s abusive, neglectful care whenever the mother asked her to because of the mother's need for help  financing her life.

And she never called the police about any of the abuse. The only time she even threatened to do that was when the stepfather threatened her, and he responded by hitting her so hard on the side of the head that she had hearing damage. And yet still no call to the police.

Mary was generally ignored to the point where she was often given no food for days. Stepdad came into the picture after the girl had been raised for a time by the grandmother. (The fact that he was not a primary attachment figure originally might have made it easier for Mary to follow her mother’s instructions to shoot him). 

Stepdad beat her frequently, and the only things he had to say to her were names like “you little redheaded brat!” He had a job which took him away from the house for significant periods of time, but mom didn’t take care of her daughter either – she would go off to party at some nearby apartments. She rather openly had affairs even though she knew her husband was a violent alcoholic and would find out and beat her as well as the kids.

Pretty amazing stuff.


 

Thursday, February 8, 2024

New Podcast, Part II. Family Dysfunction Effects Not "All in Your Head"

New podcast, Part II, discusses my family dysfunction model in more detail. Your problems with it are not "all in your head."


https://www.youtube.com/watch?v=pjG5LbV26ps






Tuesday, January 30, 2024

The Canceling of the American Psychotherapist

 


In my review of the book, The Coddling of the American Mind by Haidt and Lukianoff, I focused on a cultural shift on college campuses that has often led to an environment characterized by political correctness rather than free and open debate between opposing viewpoints. Groups have even turned on their own members for deviating ever so slightly from a “party line.” I discussed how this is one way that groupthink can manifest itself.

A  new book by Lukianoff and Schlot talks about how this situation has apparently gotten much worse, and has spread to other educational institutions and vocational venues such as journalism.

One of the most problematic ideas of groupthink on campuses has to do with the so-called Diversity, Equity and Inclusion (DEI) philosophy. Of course, diversity, equality (of opportunity, not of outcome), and inclusiveness are virtuous and wonderful things when applied to individuals with all of their family and historical influences and experiences. Unfortunately, this has now morphed into defining people entirely by their ethnic group. Members of groups are either ALL victims (ALL black people) or ALL oppressors because they may have benefitted in some  way from their “advantages” (ALL white people). 

Apparently except for Jews, who have been just about the most oppressed group for the longest time over history but also somehow counted some of the world's most successful people among their numbers. This obvious rebuttal to “Critical Theory” has been solved by some people by seeing Jews as White colonialists, while by others seeing them as Colored. Whichever is convenient. These people are still trying to figure out how to classify Asian Americans who aren’t white but who are who also more successful on average than other American groups.

This is in fact exactly the opposite of what Martin Luthor King preached! He spoke of judging people by the content of their character and not by the color of their skin.

But no matter. The primary reason that I am reviewing this book is because this type of thinking has now spread to psychotherapy teaching programs! Your problems all now seem to originate, not from your family or personality or genetics, but from the fact that you are either an oppressor or a victim, according to your group identity, and you need to admit it! As the authors say, “It’s not about your problems. You are the problem.”  

Everything wrong with people is seen through this lens. Therapists are now lecturing patients who have “incorrect” political views. “Multicultural and social justice counseling competencies” has even been endorsed by the American Counseling Association. The American Psychological Association is beginning to follow suit. They endorse, for instance, the idea that the repression of feelings of males typically seen in many cultures (who, say, won’t cry), often modeled by parents, is an example of traditional masculinity invariably being “toxic.”

The authors of the Cancelling book believe that these approaches are counterproductive. They can cause patients to see themselves only as helpless victims, and discourage people who are automatically assumed to be perpetrators from seeking help. How do these therapists reconcile themselves to the fact that, in 2020, 70% of completed suicides were “privileged” white males (according to the American Suicide Foundation).

When I first read the chapter about psychology programs I was a little unsure how common this was, since I hadn't heard about it. But then I saw an advertisement for a book for therapists in the Psychotherapy Networker magazine. It was called Decolonizing Therapy by a PsyD named Jennifer Mullan. I quote from the ad: "Ignoring collective global trauma makes delivering effective therapy impossible; not knowing how to interrogate privilege (as a therapist, client, or both), and shying away from understanding how we may be participating in oppression is irresponsible." 

Well, I do believe a therapist has to understand what each family may have experienced in this regard to understand certain shared intrapsychic conflicts that are seen within a given family - but each family is unique. And hopefully the therapist is not acting out blatantly racist attitudes. To assume all white therapists are doing this is what is irresponsible.

Anyone who disagrees in some graduate programs is in high danger of being “cancelled” by fellow students. One student said the environment was so mean that a student who lost a family member to COVID was afraid to tell anyone lest they be told that they were crying “white tears” and lectured about how people of color were the real victims of the pandemic!

Now of course it is true that many people have been severely traumatized  by racial or group experiences and that such trauma can lead to psychopathology, but that is not the same as saying that other factors might not be equally or even more important.

This is a perfect example of one key feature of Groupthink: either/or or black and white thinking. No context, no subtlety. I recently had a negative personal experience with that type of thinking with psychology interns I used to lecture to. This one didn’t involve oppressors vs. victims, but there was a certain similarity in its misclassification scheme. And it’s something brand new.

I used to lecture them about borderline personality disorder (BPD). The interns came from the University of Tennessee Health Science center and another group of interns from the Memphis VA. Now admittedly I did discuss some of my own, outside-the-mainstream ideas, but I also discussed other current psychotherapy paradigms and theories about the disorder. 

After I retired, I was still invited back every year to give the talk. Then suddenly the person in charge who called me to do this stopped calling. It took me two or three years to find out why, but I finally was able to corner her. First the VA, and then the UT interns said they no longer wanted lectures about doctor’s individual practice experiences (mine was over 35 years), but only from people who did literature reviews or active researchers! 

This same type of thing was happening on my Psychology Today blog. One post I wrote was rejected because, they said, it was an opinion piece not based on research - when most of their posts are NOT research based. They just, for the first time in years, didn't like my opinion. So I stopped posting.

As readers of my blogs know, the literature in both psychotherapy and BPD is weak - and that's being generous. It is characterized by false assumptions, the fact that whole schools of therapy are evaluated but not the individual interventions which comprise them, the ignoring of many obvious impacting factors, and clinically-useless correlations between certain symptoms within one diagnoses or between two of them. People with a lot of clinical experiences in this area are a hell of a lot more knowledgeable than researchers. 

The interns even wanted solely literature-based reviews a about the treatment of transgendered patients, which has barely begun as a subject for any studies at all!

If a therapist is more interested in politics and your ethnic group than in you, drop them ASAP and find another therapist.


Thursday, January 4, 2024

Perpetrators of Domestic Violence

 



A new article in the blog ACE’s (Adverse Childhood Experiences) Too High  describes some new and current programs that aim to help the perpetrators of domestic violence. Not its victims, its perpetrators.

 

Help the perpetrators of domestic violence and not just its victims? Whoever heard of such a thing? How can anyone care about them? Not a popular idea to be sure.  Perpetrators are traditionally shunted to the side as worthy only of blame, shame and punishment.


However, if we want to actually decrease the incidence of domestic violence, we have to address the behavior of everyone involved. In fact, initial data shows that these programs reduce the level of recidivism among arrested wife beaters.  These healing  programs, most developed in the last decade or so, show a zero to 8 percent re-arrest rate over months or years, instead of the traditional rates of 12% to 60%. 


And the whole domestic violence situation is often a lot more complicated than it seems.


Sorry, it's not “blaming the victim” to point out that, according to the National Domestic Violence Hotline, it takes a victim of domestic violence on average seven times before they leave an abusive relationship for good. So not like they have nothing to do with it at all. What message does their going back give to the perpetrator? He’s usually aware that this is a puzzle: Why does she want to be with someone who treats her like that? Furthermore, why does he want to be with someone who pisses him off so much? Often abusers have themselves been victims of child abuse as children, and/or observed such things as domestic violence or drug abuse by their parents. 


Of course this does NOT excuse the violence. Abusers already know that what they have done is wrong, so any attempt by someone to excuse their behavior seems to them to be disingenuous, and therefore they would not take it seriously.  However, understanding them is a mechanism that can be employed in helping them gain control and alter dysfunctional interactions with their spouses. 


The ACE's blog article also points to the following facts to justify treating the perpetrators:

·         Many women don’t want to leave but would prefer that someone just fix        their partners; 

·         Teens who engage in dating violence often flip from abuser to being              abused

·         It’s becoming harder to tell who’s the primary aggressor, because both           parties stewed in the same dysfunctional soup when they were growing          up, and  the couples do as well in their current relationship.                  

·         Family violence and intimate partner violence are more accurate terms          for domestic violence because violence occurs between or among parents        and adult children, siblings, members of generations in the same family,         extended family or in gay relationships

·         Abuse is also emotional and financial, something for which it’s                   difficulto make an arrest.            

 

Family violence is at the root of many problems in any community: over-crowded courtrooms and jails, burgeoning child welfare caseloads, increased youth violence and gun violence, increased healthcare costs and homelessness—a significant portion of what a community spends its tax dollars.

 

Healing-centered programs require that an abuser take responsibility for the actions that lead to his or her arrest.  One of the themes of this blog is the ongoing relationship between child adversity and dysfunctional relationships. To get to the bottom of the problems of any given couple, in my opinion this absolutely must be addressed for both parties as well as for their own relationship. 

 

Although the various patterns of the intergeneration transfer of dysfunctional patterns that I describe in my blog are not well understood in the field, some people teaching healing-centered batterer interventions course are steeped in the science of childhood adversity.

 

The rest of the ACE's blog post describes more details of several of these programs throughout the country. There would probably be more of such programs, but the risk of being cancelled if you show any empathy at all towards abusers is high. That hurts the victims of domestic violence just as much as it does the perpetrators.


Tuesday, December 12, 2023

Pornography Addiction





Is pornography addiction a real condition? In the book I co-edited, Groupthink in Science, we have a chapter by Nicole Prause, a neuroscientist who has been very active in this debate (and is mentioned prominently in the book I’ll be talking abut). She makes what I consider an extremely good case that this “addiction” model is nonsensical. I agree.

In her book, The Pornography Wars, academic sociologist Dr. Kelsey Burke examines in fine detail both sides of this ongoing debate without clearly taking a position either way. She talks with a variety of academics and members of interest and church groups and gets them to open up considerably about their opinions. Clearly, a lot of the debate is based more on ideology than on science. On both sides! As we all know, sex is a subject that has created a huge disturbance in human culture, what with religion, gender issues, Victorian culture, and the like.

My own view is that sex negativity is still rampant in the United States, despite the fact that most people these days engage in it prior to marriage. They often feel somewhat guilty about it afterwards. Interestingly, this has put radical feminists and religious fundamentalists on the same side of the pornography debate. What strange bedfellows indeed.

Now, to be extra clear, sex trafficking and being forced to participate in a porn film are issues that are completely legitimate. No one should be forced to do anything like this against their will. But in my mind, those issues are very different than the question of whether pornography per se is bad for anyone, and if so, who and in what way? Or the question of whether watching it compulsively in maladaptive ways is a “disease.”

I believe questions about addictions as true mental diseases should be limited to those substances, such as alcohol and opiates when used to excess, lead to tolerance and serious withdrawal symptoms. Just about anything can be used to excess and create negative consequences for the users and their associates. To me, most so-called “addictions” are nothing more than self-destructive behavior designed to have certain affects on family relationships and romantic partners.

I’d now like to list a few examples of the evidence for what I am saying here from the book in question. Research in this field, the author points out, depends on self-reports by subjects - which is not objective data, and which are highly dependent on the types of questions researchers ask and how they are phrased. There is, for example, a phenomenon called acquiescence, in which subjects’ responses are likely to go along with the values implied in the question - for example asking only about negative consequences but avoiding questions about positive benefits.

Lying about issues with moral implications is widely prevalent. Does anybody really believe that a female brought up in an evangelical religion will admit to secretly enjoying watching porn and having experienced no actual negative consequences from doing so outside of maybe feeling guilty? Additionally, it is obvious that people’s beliefs about porn influence the consequences they experience during and after watching it.

Another issue is correlation versus causation. Is watching porn bad for marriage, or does a bad marriage lead to more porn viewing? An interesting finding: Protestant men are more likely than any other, group, including atheists, to consider themselves addicted to porn. Yet they report watching less porn than the other groups. Several studies show that religious commitment is a better predictor of people believing  they are addicted than actual porn usage.

As I have discussed in several other posts, the fact that the brain’s connections are plastic and change all the time when exposed to environmental influences makes claims that neuroscience has “proved” that a porn “addicted” person has an organic disease incorrect. As Dr. Burke points out, nature and nurture and their interactions are what lead to most brains study results. And the boundaries between these things are “far from tidy.”

Another point: just because someone has a higher libido than someone else does not mean that they are sex addicts - they just want sex more often. Also, home porn may often be a cue for some other reward like masturbation. In a laboratory setting, contingencies like these aren’t in the cards.

Then there is a prominent Protestant theological teaching.  A quote from one of Billy Graham's recently posthumously-published newspaper columns sums it up concisely. He writes, All people are sinners in need of a Savior.” What this means is clear from his sermons: prohibited but universal individualistic desires such as lust are evidence that we are all evil in the eyes of God and need to renounce our biological nature and follow what God – really the church – tells us to do. Or else. In the words of a woman at a church group’s conference on the harms created by porn addiction, "...after the Garden of Eden we’ve been running from God ever since.”

This also has led to perceptions about men versus women’s sexuality. Religion teaches us that sin was created by a woman’s curiosity when Eve bit into the apple. In the middle ages, women were actually considered the lustier of the two sexes due to the impurity associated with Eve’s curiosity. In the 1800’s during the industrial revolution and mass migration from family farms into cities, this changed into its opposite: women changed from Eve to Mary. Women were thought to want sex, not for itself, but only in order to insure the commitment of marriage. “Why buy the cow if you can get the milk for free?” was a question asked by confirmed virgins. Although men were thought to want sex way more than women, they were also perceived as being less in control of their behavior. Masculinity was defined as being in control, so if they “conquered” the natural sinfulness of a porn addiction, this was thought of as an accomplishment.

In my opinion, the function that all this mythology serves is to show the negative effect of allowing yourself to express lust, so the people who are doing without get to feel more justified in giving freer sex up. Said one Christian who had “overcome” a porn “addiction,” quoted in the book, he was “…tired of not being the person that God made me to be.”

Well, what about those radical feminists? They are certainly not primarily evangelical Christians. Nonetheless, they have without realizing it accepted the Christian dogma while trying to frame it as something else. Both Evangelicals and radical feminists believe that men feel entitled to sex and women are both objectified and victimized. The radical feminists seem to implicitly accept the idea that women cannot want and enjoy sex as much as men, despite the fact that they can have multiple orgasms and men cannot.  The general sex negativity towards women's lust prevalent in both sexes  in our “patriarchal” society  was summed up nicely by Elise Loehnen: "Good women want to be seen as sensual, warm and inviting of sex, but not overtly interested."

Because of the prevalence of these gender attitudes and in order to sell more, porn does in fact  frequently show women being objectified by men. The feminists  use this to “prove” their point, ignoring that this occurs because of the cultural groupthink expectations of the audience. And there are plenty of women who somehow enjoy watching porn as much as men do even under these circumstances.

Thursday, November 16, 2023

Racism in Medicine

Opening of anatomical theater at medical faculty at Bogomolets National Medical University circa 1853

                                               Unknown author.  Creative Commons Attribution-Share Alike 4.0

 

When I read the program for any medical meeting, such as the annual American Psychiatric Convention, there has for years been a plethora of talks and  forums about racism in medicine, equity and diversity, and the like. Perhaps medical offices really are rife with bigotry and a lack of concern for minorities – particularly black people.

Now don’t get me wrong. I’m sure there is still some racism in medical practice perpetrated by today’s doctors, just as in the rest of society. But people seem to lose sight of the fact that there has been tremendous progress in decreasing it in most of U.S. society. As author Steven Pinker writes in his book Enlightenment Now: "But it's in the nature of progress that it erases its tracks, and its champions fixate on the remaining injustices and forget how far we have come." (p. 215).

I once got into an argument with a young African American woman about this. She said there hadn’t been any progress here, even after the civil rights movement!  The odd thing was that at the time we were enjoying a meal at a restaurant here in Memphis. I reminded her that when I was a kid, we wouldn’t have been allowed to eat together like that. In fact, she probably would not have been allowed in the restaurant at all. Her answer? Something to the effect of “Well, they still don’t like us here. It was probably better when it was out in the open.”  Really? 

The problem with poor outcomes in medical treatment for Black patients has several different causes besides racism, such as poverty, the crazy medical insurance situation in the U.S., and what I'm about to talk about. To hasten further progress, ALL of the various causes should be addressed. And before accusing me of "blaming the victim" in what I'm about to discuss, please keep two things in mind. 1. Just because behavior can be easily understood and justified does not automatically mean that it can't also be counterproductive. 2. When it comes to the results of repetitive human interactions in current U.S. society, "It's all my fault" and "I had nothing to do with it" are almost always false positions to take.

I’ve written before about the “game without end” aspect of relationships between Blacks and Whites (7/23/13, 1/17/13, 4/3/12). The basic point is that a lot of difficulties in the current relationships between Blacks and Whites stems from past racism, not current racism.

In a study presented at the 2023 American Association for the Advancement of Science annual meeting, Somnath Saha reported that he had came across a cluster of studies showing that black people with cardiovascular disease were treated less aggressively compared to White people. This professor of medicine at Johns Hopkins University began poring through medical records. He found that doctors are more likely to use negative language when describing a Black patient than they are with a White patient. He found them described as “really difficult,” “non-compliant,” and “uninterested in their health.”  He attributed this to implicit bias by physicians— unconscious judgments that can affect behavior.

Now, again, implicit bias is a real thing. We ALL profile other people, because we can't read minds. But is that the whole picture? Two studies bring up an important point. In an article talking about Saha’s study, Antoinette M. Schoenthaler (a professor of population health and medicine at New York University's Grossman School of Medicine), said that disparities in pain management are pervasive and widespread across the medical profession. But she also mentions a reason for it that is seldom brought up: "Patients of color go into an appointment with feelings of heightened anxiety because they're expecting mistreatment.;  we've seen minoritized patients have higher blood pressure in the context of a clinical visit because of these expectations of anxiety and fear, and disappointment."

Medical mistrust leads to greater health disparities in minority communities, according to a poster presentation at DNPs of Color annual meeting held in Washington, DC, October, 2023. It is not a phenomenon but a “true medical issue,” said Clydie Coward-Murrell, MSN-Ed, BSN, RN, an African-American. “This clinical issue is not as prevalent in other minority communities simply because of the atrocities in health care that African Americans had to suffer for hundreds of years.

Can anyone blame black patients for being suspicious of white doctors? They seem to all know about the Tuskeegee syphillus experiment in which severe damage was done to black patients. They may even know that black surgery patients were in the past given less anesthesia than whites because doctors thought they had a higher pain tolerance – a myth left over from slavery times invented by slaveowners so they would not feel so bad about whipping them. They'd literally have to be crazy to completely trust doctors.

So maybe that’s part of why they seem to be angry and non-compliant with medical treatments? And if that’s true, then couldn’t that be a significant factor in explaining why other studies show that black patients seem to have worse outcomes than white patients with similar conditions? Because they don’t follow doctors’ orders as blindly? In that vein, let me tell you what one of my black psychotherapy patients told me: She had to hide the fact that she was seeing a therapist because her fellow church members would give her an extremely nasty round of criticism if they knew. Accusing her of just not praying hard enough.

In my own experience as a medical student, resident, and psychiatrist, I have not personally witnessed a whole lot of obvious racism in my instructors and colleagues. Of course I am not black so I might not have seen racism that was present since it would not be directed at me. But I was a residency training director at a Southern medical school for 16 years. I had a lot of black psychiatry residents, and none of them complained about this. 

We were told by the dean in charge of residency programs that, although our school did not have affirmative action, if there was a black applicant and a white one of roughly equal qualifications, to take the black one.

The only time I ever personally witnessed really nasty racism (and simultaneous sexism) among doctors was way back in the early 70’s when I was a medical student in San Francisco. Clearly, my school was ahead of its time so I had a biased sample – my class was 20% female at a time when there were a lot fewer elsewhere (there are now more female medical students than male ones). A Black female classmate wanted to become an orthopedic surgeon. Surgeons were by far the biggest Neanderthals for these issues back then. Boy, did they ever give her a raft you know what when she applied.

So all this talk among doctors about how racist they all are is not something that only they hear. Black people hear it too. So what they are hearing is that they are right to be suspicious of white doctors. While racism in medicine must still be addressed, talking about it way too much has the potential to backfire and make the problem worse rather than better.

Monday, October 23, 2023

I am Interviewed on Two New Podcasts



 I'm interviewed on two new podcasts. 

The first describes my background and how I got interested in the family dynamics of self-destructive behavior (particularly borderline personality disorder) and its psychotherapy:


https://www.youtube.com/watch?v=XPQdl664QgM




In the second one, I talk about my self-help book, Coping with Critical, Demanding, and Dysfunctional Parents: Powerful Strategies to Help Adult Children Maintain Boundaries and Stay Sane:


https://www.youtube.com/watch?v=MLM6tvLe_Oo&list=PLOSSy_bIynJqUnE3ilzI9UR7J92aYeCI2&index=42







Tuesday, October 3, 2023

Genes vs Environment: Neuroscience Nonsense

 

Functional magnetic resonance imaging by Washington Irving, public domain


In an article in the Washington Post on 8/2/23, cultural critic Kristen Martin wrote an essay about how some best-selling books express great confidence in theories of the brain that are in reality still in their infancy - and unproven. She mentions a book I reviewed, The Body Keeps the Score by Bessel van der Kolk, a well as The Grieving Brain by Mary-Francis O’Connor.

The author believes that “neuroscientific wisdom is now recirculating into new mediums, calcifying into consensus that we can’t stop parroting.”

In reality, our understanding of the human brain, while increasing rapidly, is still in its infancy. Scientists have to contend with about a trillion connections between billions of brain cells that constantly change in response to the input of literally thousands of environmental and interpersonal influences (neural plasticity). I have written several times about how this problem manifests itself in studies using a type of brain scan called an fMRI, which basically measures blood flow in parts of the brain as the brain’s owner is engaged in a variety of mental tasks.

Another doctor likened trying to make any generalizations about repetitive behavior from observable differences in brain scans to trying to know how the stock market is doing by measuring electricity usage at the stock exchanges.

I write about how results that differ between groups are labeled as “abnormalities” when in fact they might indicate normal differences in the performance of the task in people who have had differing prior experiences and have learned to approach the task in different ways. They may be accomplishing differing goals - and without having to engage in conscious deliberations.

Martin also says that people consult neuroscience to validate what they want to believe or what they already know. “Tracing all of our messy emotions, reactions and habits to the workings of electrical currents and neurochemicals lets us off the hook.”

She references some work with brain scans that adds even more fuel to our opinions on the matter. In 2009, a neuroscientist put a dead salmon through an fMRI and detected activity in its dead brain. It is easy to produce a false positive finding just from statistical noise in the scans.

She adds, “A scan can correctly identify the areas of a person’s brain that are receiving blood flow at a particular moment, but we can’t definitively say that activation of a brain region equals a particular emotional or cognitive state.” A part of the brain called the amygdala produces negative emotions like fear, but also positive ones, like happiness.

Even more striking was a review from 2020 by Duke University professor Ahmad Hariri. It reanalyzed 56 published academic studies based on fMRI analyses, and found that the results usually do not come out the same on a second scan.

As I have also written about extensively, misleading fMRI study results are routinely injected into the still highly prevalent nature-nurture debates in psychology and psychiatry. Genetic influences on behavior are routinely exaggerated by the field in conclusions that are based on brain scan research.