Do Those with Behavioral Disorders Act the Way They Do Because of Personal Defects?

 

"Dance" by Eugenio Barba Theater. Public domain.

Many mental health providers treat all suffering as if it’s all due to some personal defects that need to be fixed. To be  fair, major psychiatric disorders like schizophrenia are almost certainly due to brain defects (despite what you may hear). So those do indeed need to be “fixed.´

But what about patients who have repetitive self-destructive or depressogenic behavior or repetitive self-initiated relational issues? Why do they act the way they do?

When we watch someone else react in their own typical way to a certain environment, we all have a tendency to attribute their behavior more to their own internal predispositions and to discount the environmental factors that they are reacting to. This is called the Fundamental Attribution Error as described in a previous post, and it is rife in the psychology and psychotherapy literature. You’d think most psychologists would be aware of that, but few of them are. My biggest beef with most psychotherapy schools is that they think these issues are all in the head, as if the surrounding social environment has nothing to do it, or at the very most, does no longer.

So what are these defects said to be? Mostly one of three things: The person is said to be either mad, bad, or stupid. Crazy, evil, or has an IQ lower than that of a lizard. We might add a fourth one: the person is a masochist who enjoys suffering,.  From an evolutionary perspective, that would be bizarre. The whole point of pain from the that perspective is to get the organism to NOT do something. Maybe these folks only say they enjoy pain in order to accomplish some social objective  - and leave out a lot of other important information.   (One exception to this may be the self mutilation done by people with borderline personality [BPD]. That seems to lead to the release of endorphins – an opiate-like substance - in the brain, which might relieve pain. I find they often do that to create for themselves a distraction from another, worse type of pain – the helpless feeling of not knowing how to solve a highly threatening and pressing problem)

Most people who do seemingly stupid things repeatedly have a ulterior motive for doing them which they keep hidden .They are almost never crazy, evil, or too stupid to know what’s obviously going to happen when they act that way. They can even tell you that they are well aware of what’s going to happen if you politely tell them you can see how bright they are.

Readers of this blog can probably predict what I think is motivating to act in these ways. They are sacrificing their own well being in order to solve an even bigger family problem. And it does work, at least over the short run. So they keep mindlessly repeating it over and over.

Even the therapy schools that acknowledge that a troublesome environment is a big part of problem seem to focus on helping patients suffer through them more easily, without working on changing the problematic family behavior itself. A good example of this is Dialectical Behavioral Therapy from Marsha Linehan, the most prominent and often-used treatment designed for people who have BPD. It seems to mostly ignore what she herself says is one of the two big factors that cause BPD: The invalidating environment.  The one they grew up with and to which they are still subjected. She doesn’t even seem to specify the context of the invalidating environment, why people do that, or even who is doing the invalidating.

Some therapists believe that, in many cases, helping a client to work on changing another family member's behavior is impossible, so they focus instead on self soothing. They are wrong about that.

Behavioral Disorders are not "All in Your Head"

The serenity prayer: 

God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.

 

When I read psychotherapy journals and posts on psychotherapy list-serves, it often sounds to me like the field has lost its collective mind. Some authors seem to think that every behavioral syndrome results entirely from some deficiency within a person, rather than being mostly a reaction to their social environment (the fundamental attribution error). If their patients are upset or anxious, they ask them things such as what is wrong with your thoughts or why they don’t know how to calm yourself down (cognitive behaviorists). Or what might be their deep-seated desires that they won’t face (psychodynamic therapists). 

(To be clear I’m not talking about major psychiatric disorders that are most likely real brain diseases such as schizophrenia).  

While these types of questions can be helpful for people who are not very disturbed about their lives and relationships, sometimes their use has been comical. As a psychiatrist named Jim Dillon put it:

“As a psychiatrist, I cringe upon hearing recommendations for psychotherapeutic methods employed to resolve ongoing social conflicts. It is like suggesting labor unions obtain group counseling when the threat of a strike is the only strategy that will improve their economic circumstances.”

Or teaching clients “mindfulness” when they are being invalidated, criticized or abused by their family and spouses - instead of helping them learn how to put a stop to the dysfunctional interactions.

 

As I described in a previous post, more systemic or social types of therapy that involve family members (family systems therapy), while still out there and being employed by masters’ level therapists, have fallen out of favor with psychologists. And they were never taught to psychiatry trainees at all (except in a residency program that I ran). This has occurred because of a number of social issues. Examples: Feminists thought systems people were blaming just women, who are still the primary caretakers for children;  some folks believed that there were people using the “abuse excuse” for criminal behavior and to avoid taking any personal responsibility for their problems; unscrupulous therapists were uncovering “false memories” of abuse through suggestions to the highly suggestible, as well as through hypnosis.

 

That last one also points to another issue that shows the field’s current state is more political than scientific. Just because some of the ideas therapists' used for problematic behavior were being misused in some contexts does not automatically make them invalid. Furthermore, if some of aspects of complex theories are wrong, that hardly means that all of them are wrong.

 

These phony arguments are also used to further the financial interests of  pharmaceutical companies, who want to sell more pills. If everything is a disease, drugs should be all you need. They are also used by the medical insurance companies. These insurers refuse to pay for any longer-term psychotherapy treatments in order to better cash in. They only cover symptomatic treatment. Bogus “medical necessity” criteria are used to drastically cut down the number of sessions therapists can administer. In other words, the current models help the greedy. The federal parity law that says psychiatric disorders must be paid for by insurers just like physical disorders has been a complete joke.

 

Science has clearly shown beyond a reasonable doubt that the structure of the “plastic” human brain is in part shaped by interpersonal interactions. Most of what we do in social situations is learned (or intuited as I believe some are),  and is then done automatically in response to environmental clues. The brain has about 6 Billion neurons with up to a thousand connections each, and the circuits change in response to what is learned. And learning also includes how to best react to literally thousands of environmental factors operating at different times, strengths and combinations.

 

An article published by Harvard University Center for the Developing Child says that 700 new connections per second are made in the brains of newborns within the context of care-giving relationships  Another recent study showed that small differences in a mom's behavior early on in interactions with infants may possibly show up in child's epigenome (epigenetics is the study of how genes are turned off and on in response to such things as social interactions).

 

It is time for therapists to learn, not how to change their clients’ “internal” family system (another recent therapy fad), but how to help them react better to their external one.

Cognitve Behavioral Therapy "Evidence-Base" Grossly Exaggerated

In my post on my Psychology Today blog on November 21, 2011, I discussed how the purveyors of today’s most predominant psychotherapy methodology, cognitive behavioral therapy, grossly exaggerate the strength of their research evidence base in the psychotherapy outcome literature.

My opinion was recently confirmed in a review of meta-analyses of the CBT literature in the Journal of the American Medical Association, published online September 21, 2017 (“Cognitive Behavioral Therapy the Gold Standard for Psychotherapy:  The Need for Plurality in Treatment and Research” by Falk Leichsenring and Christiane Steinert).
 
They reported that a recent meta-analysis using criteria of the Cochrane risk of bias tool reported that only 17% (24 of 144) of randomized clinical trials of CBT for anxiety and depressive disorders were of high quality. The “allegiance factor”—study authors were CBT therapists themselves and often designed the studies to make their treatment look better than it was, and opposing treatments look worse that they were—was rarely controlled for.

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—the sizes of treatment effects were only small to moderate and might eventually even be found to be due to the allegiance effects.

In panic disorder, CBT was not more effective than treatment as usual but only to being on a waiting list.

Even with these amazing biases, for depressive disorders, response rates of about 50% were reported. This was true for anxiety disorders as well. “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. Conclusion: a considerable proportion of patients do not sufficiently benefit from CBT.

Last but certainly not least, there was no clear evidence that CBT was more effective than other psychotherapies, either for depressive disorders, anxiety disorders, personality disorders or specific eating disorders.

Personally, my biggest beef with CBT and other psychotherapy outcome studies has less to do with symptom relief than with actually changing maladaptive interpersonal behavior. The latter is almost never even looked at, let alone measured in these studies.

CBT’ers seem to think anxiety, depression, and self-destructive behavior are all due to screwed up thinking by individuals rather than being normal reactions to stress-inducing environments. In experimental psychology circles, this is known as the fundamental attribution error. Telling people with these particular symptoms that their problems are basically “all in their heads” in this manner is very invalidating for them.  Ironically, an ‘invalidating environment” is one of the two primary factors these very same therapists cite as the main causes for borderline personality disorder.

Where Psychotherapy Goes Wrong

In my post of November 4, 2014, I discussed something called the fundamental attribution error. As described by Richard Nisbett and Lee Ross, this is defined as “the assumption that behavior is caused primarily by the enduring and consistent disposition of the actor, as opposed to the particular characteristics of the situation to which the actor responds.” That post discussed how this error results frequently in mistaken conclusions that are drawn based on studies of people with personality disorders.

It is also the main reason why psychotherapy has not really progressed much as a science in the last 25 years or so.  The 1980's and early 1990's were a period of amazing creativity in the field, during which new ways of looking at human behavior and new interventions to help change that behavior seemed to be coming out every day. In particular, family systems thinkers began to realize that the causes of behavioral problems like self-destructiveness, as well as the causes of symptoms like chronic dysphoria and anxiety, do not reside entirely within the heads of the people coming for help.  

Some of it can be a normal and adaptive response to a very abnormal interpersonal environment. The "attachment" literature, which is fairly strong, shows that kin behavior has a huge effect on the psychological stability and the relationships of all human beings.  Much more so, I always say, than the food pellets and electric shocks favored by behaviorists.

Due to the wide variety of independent factors listed in the masthead of this block, family systems ideas have, unfortunately, been left behind to a significant degree, and therapists are back to looking at people as if their problems were "all in their heads."

Critics blasted systems ideas by focusing disingenuously on areas about which family systems theorists were completely wrong - like the genesis of such real brain diseases as schizophrenia (and yes, the evidence that schizophrenia is truly a brain disease is overwhelming, so spare me the "myth of mental illness" bullcrap). They pulled the usual slick ploy of making arguments based on black and white thinking: if family systems theorists were wrong about some things, then they must have been wrong about everything.

Because the effectiveness of psychotherapy interventions meant to change interpersonal behavior are hard to prove in a treatment outcome study, the systems people were also accused of being unscientific. As if observation were not the first step in the scientific method! (So much for much of what we know about astronomy). "Outcome studies" were touted as definitive proof of various treatment methods, despite the fact that they are extremely limited in their overall validity because there are almost an infinite number of variables that cannot be controlled. And they cannot be double blinded. And the therapists who are participating are not all doing exactly the same thing.

And the studies that are touted show only exceedingly modest effects in those subjects who do improve, as well as showing that a significant percentage of subjects did not get better at all.

Then there is another important fallacy that psychologists discuss: confusing an inference about an observation with the observation itself. Or, in other words, jumping to conclusions, and then acting like the those conclusions are facts. Andrew C. Papanicolaou, Ph.D, a neurobiologist at the University of Tennessee Health Science Center where I used to work, observes,  "Scientific discourse is unique in that it aims to maintain clear distinctions among assumptions, hypotheses and facts and treat each of them appropriately. Although this aim is often attained, it is rarely attained fully and occasionally is not attained at all."

Especially in psychiatry and psychology.

There's this rather big issue of what is really going on with patients, as opposed to what looks like is going on.  If you do not think people have hidden ulterior motives for their behavior, secrets about themselves that they don't want to share, and lack a complete understanding of the behavior of all of those around them who affect their lives, then I am afraid you are living in an alternate universe.

But still, therapists observe their client's performance, and confuse it with ability, as described in a previous post. Even when therapists look at what is basically interpersonal behavior, they make this error. Good examples of this are two of the current "evidenced-based" therapies for borderline personality disorder (BPD), Schema Therapy and Mentalization-Based Therapy. Both posit that people have mental models of how to behave in the interpersonal world, as well as of the motives and intentions of other people in their world. 

In schema therapy, the theory correctly asserts that these mental models or schemas are built up in childhood through interactions with primary attachment figures. It then goes about trying to change those schemas that it identifies as "maladaptive."  Surely, they are maladaptive in some ways, but that they serve no adaptive purpose at all is just assumed.

Although these therapists have started to look at how the primary attachment figures of their patients are behaving in the present , I have not seen much about the fact that schemas are continually updated (through the Piagetan process of assimilation and accomodation) during a person's ongoing interactions with those attachment figures. To understand what is really happening, you also have to look at the schemas of those other people.  The schemas of the various players in the family drama interact with one another!

Mentalization therapy also deals with a person's mental models of the motivations and intentions of other people, but just assumes that the mental models of their patients with BPD are distorted. This is based entirely on the way the patients respond to others, while completely ignoring the motivations and intentions on which that behavior is based. Maybe the patient wants other people to think they have distorted mental models. Why? Because they are playing the role of spoiler. The incorrect assessment of the accuracy of the patient's mental models is confused with the feigned actions of that patient.

Sorry, but we cannot read minds. You have to look at both the behavior and the history of everyone involved, and even then you can get a highly distorted picture yourself. So therapists should quit accusing their patients of what they themselves are doing - distortion.

People who have a history together base their behavior on that entire history, not just what is going on at any particular moment.  And when they talk, they can leave a lot out (ellipsis) and still understand each other, because they both already know what both of them already know. An outside observer does not know these things, and therefore their conclusions based entirely on what is said in front of them can be way off.

Of course, it is true that a therapist can never be absolutely certain of anything. For that, you would not only need a movie camera with sound on all participants 24 hours a day like in the Truman Show, but this equipment would have to be in place throughout the entire lifetime of the patient since birth!  

Still, the more information therapists can gather on the whole picture, the more likely it will be that they will better understand what might be going on and figure out what can be done to change it.

But first, they have to stop their myopic focus on that which is going on entirely in the patient's head.

An Unwarranted Hidden Assumption in Research on Personality Disorders

One of the major reasons I became interested in family systems theory, tribalism, family myths, social psychology, and other manifestations of collectivism was because I noticed a big problem with the major forms of psychotherapy practiced on individuals: psychodynamic and cognitive-behavior therapy, and, though to a lesser extent, humanistic therapies like Gestalt therapy.  

All of these forms of individual therapies pay way too much attention to the way patients are reacting, and not nearly enough attention to what it is they are reacting to.

It’s a bit like looking at someone who is falling apart after recently having personally witnessed their entire family being beheaded by terrorists, and concluding that he or she has “poor distress tolerance coping skills.” Well, maybe not quite that bad, but you get the idea.

Some psychologists talk about something called the fundamental attribution error. According to Richard Nisbett and Lee Ross in their 1980 book, Human Inference: Strategies and Shortcomings of Social Judgment, this is defined as “the assumption that behavior is caused primarily by the enduring and consistent disposition of the actor, as opposed to the particular characteristics of the situation to which the actor responds.”

Richard E. Nisbett, Ph.D.

Of course, internal predispositions, one's past history of learning due to environmental reinforcement, and free will are very important in determining how people are going to respond to a given situation. With people who have personality disorders in particular, however, to say that their living in a family war zone, as frequently described in this blog, is not a huge part of the problem seems to me to be the height of absurdity.

I thought of this issue recently after reading an article entitled “Ecological Momentary Assessment in Borderline Personality Disorder: A Review of Recent Findings and Methodological Challenges” (Santangelo, Bohus, & Ebner-Priemer, Journal of Personality Disorders 28 (4), pp. 555-576). 

Ecological Momentary Assessment (EMA) is a research technique designed to look at behavior and internal processes outside of the confines of what is called retrospective reporting. Retrospective reporting is the subjects' response to questionnaires about the way they normally respond in their daily lives - in hindsight.

People in studies using this technique are given a diary to fill out several times per day at regular, fixed intervals as they live their normal lives. They are instructed to record certain feelings and reactions they are experiencing. In the article’s abstract, it says that EMA is “characterized by a series of repeated assessments of current affective, behavioral, and contextual experiences or physiological  processes while participants engage in normal daily activities.”

As the authors reviewed the results of prior studies using this methodology in subjects with borderline personality disorder (BPD), one of those hidden assumptions I defined in a previous post just jumped out at me. The authors were inherently ignoring issues created by the fundamental attribution error. 

The definition of EMA in the article's abstract mentions “context,” by which I assume they mean the environmental context, but in the studies and in their discussion about them, the issue of environmental context seemed to be missing in action. The subjects were always asked about how they were responding, but almost never asked about what it was that they were responding to!

The authors’ literature review focused on five of the DSM’s (the official diagnostic manual of the American Psychiatric Association) criteria for BPD: 1. Affective instability. 2. Dissociation and transient paranoid ideation. 3. Interpersonal disturbances. 4. Self esteem disturbances. 5. Suicidality.

Now, one legitimate reason for doing these studies is to check on the validity of the diagnostic criteria for BPD, in which case descriptions about how the subjects’ families were behaving would be somewhat irrelevant. Since the diagnostic criteria were used to establish the diagnosis of BPD before the studies were even done, if the studies seemed to indicate that the criteria are turning out to be invalid, that would have to mean one of two things:

1.       Patients with BPD have been invariably lying through their teeth - on an impossibly consistent basis - in giving even superficial descriptions of their personal symptoms and experiences during diagnostic interviews ever since the syndrome was first recognized, or 
2.      The experimenters in the various earlier studies were lousy diagnosticians and were not applying the criteria in a valid manner.

Now, since I would assume that neither of these things was generally true, a finding that the subjects did not experience these symptoms would be most surprising. Of course, generally the subjects did experience the symptoms, although perhaps in some cases not quite in the generally accepted way. This sort of a conclusion is very close to being a tautology – that is, “a rose is a rose.”

But I digress. The authors clearly mention that some of the symptoms they are looking at occur in response to stress, but generally the subjects are not asked to describe the actual stresses to which they are responding. For instance, they say that subjects with BPD were found to be “more prone” to experience stress than controls. 

The problem with this is that it that assumes that the stressors that the controls are responding to are of equal frequency, severity, and nature as the stressors to which the subjects are responding. But no descriptions of those essential factors are presented. Perhaps if the controls were living in a more stressful environment, they would experience the stresses in a fashion more similar to that of the BPD subjects. 

Why are the subjects not also asked in their diaries to describe the stressors to which they are reacting? Is it all in their heads?  (It’s All in Your Head was the original title of my last book. Damn those academic publishers who thought that title was too colloquial). Or is it because therapists, like a lot of people these days, don’t want to look at what is actually going on in families?

Another issue is that, even if the diaries did ask about stressful interactions with intimates, and even if patients described them honestly and included their own behavior in their descriptions, the experimenters would still be in the dark about how severely stressful they were. That is because these interactions have subtexts, as I described in my post The Obvious Secret of Interpersonal Interactions Within Families. 

Words and behaviors during family interactions take on additional shades of meanings within the context of all prior interactions, and these meanings can significantly add to the stress level of the involved parties. In fact, without knowing the entire history of the patient's family interactions, the experimenter's judgments about the severity of the stress would by necessity be extremely flawed. 

As far as I know, there is only one method by which a mental health professional can obtain this data: long term psychotherapy with the involved individual. This should also include occasional conjoint sessions with the patient and family members, to get their sides of the story. The stressors of every single patient have qualities that are unique to them.

Without any descriptions of the nature of the stressors, we can not really come to valid conclusions. Of course, a possible assumption that should be made is this: people who are under severe stress are undoubtedly more likely to respond with more severe reactions than people who are under far less significant stress. 

Duh!

Neural Plasticity and Error Management Theory

One of the ongoing themes of this blog is the nonsensical practice of some researchers in psychiatry of routinely labeling differences seen on brain scans between various diagnostic groups and control subjects as abnormalities. 

Just because there is more blood flow to one area of the brain during the performance of certain tasks or a difference in size between various subsections of the more primitive part of the brain, the limbic system, in a group of people who show similar behaviors and symptoms does not automatically mean that this demonstrates a disease process.

We know now that the neural structure of the brain is extremely plastic, and many of these differences merely reflect the fact that people who have certain habitual behavior patterns routinely show these differences. Disease processes can also certainly account for differences, but just the mere presence of a difference does not tell us which of the two possibilities - abnormality or normal difference – is the accurate explanation for the finding

As I pointed out on my post Neural Plasticity on March 14, 2010, after just three months of a vigorous exercise program in one study, the size of a brain structure called the hippocampus increased an average of 16% in normal people.

So how do we determine whether a difference is or is not an abnormality? Well, one line of evidence that may help tip the balance of evidence and help us to decide is the use of something called Error Management Theory (EM). This is an extensive theory of perception and cognitive biases that was created by David Buss and Martie Haselton (Haselton, M. G., & Buss, D. M.  Error management theory: A new perspective on biases in cross-sex mind reading. Journal of Personality and Social Psychology, 2000; 78:81-91) and expanded upon in another article (Haselton MG, Nettle D. The paranoid optimist: an integrative evolutionary model of cognitive biases. Personality and Social Psychology Review. 2006; 10(1):47-66).

Martie Haselton, Ph.D.

The human species is highly adaptive to its environment, particularly its social environment. The survival of we human beings, and our ability to live long enough to have children and pass along our genes, depends on how well we can read and react to that environment. In particular, we need the ability to read the motives of other members of our species to determine whether or not we may be being deceived or endangered by them.

It making a determination about whether the environment is dangerous or friendly, it is often true that it is far better for long-term survival and procreation to err on one side or the other in making this judgment. A friendly situation might be misinterpreted as a dangerous one while a dangerous situation might be misinterpreted as a friendly one. 

Depending on the environment, a false negative or a false positive interpretation might prove fatal; hence, it is often best to err consistently in one of these directions.

The best illustration of this is the "unidentified animal in the woods" problem. If you are walking in a forrest and mistake a raccoon for a bear and run away, all you have lost is some needless expenditure of energy. If, on the other hand, you mistake a bear for a raccoon and don’t run away, you are dead.  So all other things being equal, if you cannot identify the animal for sure, it is always better to run.

So what does this have to do with neural plasticity? To illustrate, allow me return to the issue of my favorite “diagnostic” group, the patients who exhibit traits of borderline personality disorder (BPD). These folks can be extremely reactive to stress in the social environment. They tend to get more agitated that the average person in response to any perceived slight, and it takes them much longer to calm down. Their behavioral reactions tend to be sort of "shoot first and ask questions later, if at all."

It is also true that some but not all fMRI studies show that, on average, patients with BPD have slightly reduced volumes compared with normal controls in several brain areas including the frontal lobe, bilateral hippocampus, left orbito-frontal cortex, right anterior cingulated cortex, and right parietal cortex.  

Another recent study (Ruocco et. al., Biol Psychiatry, 2013;73:153–160) showed that BPD patients demonstrated greater activation within the insula and posterior cingulate cortex. Conversely, they showed less activation than control subjects in a network of regions that extended from the amygdala to the subgenual anterior cingulate and dorsolateral prefrontal cortex. 

Abnormalities, or just differences?

Well, these brain areas are involved in the body’s threat assessment as well as fight, flight or freeze reactions in response to potentially dangerous environmental situations.  Panic attacks and rage attacks, common in these patients, are also created in some of these brain areas.

Many studies have shown that the childhood family environment of patients who go on to develop BPD is often highly chaotic and unpredictable. Therefore, “normal” inhibition of fear and rage responses might be extremely maladaptive. The size and activity level of the amygdala and other limbic system structures might be gradually shaped through ongoing environmental interaction, so that on average they look different than "normal" control subjects.

Voila. If prospective (studies in which babies are followed for many years) studies showed this hypothesis to be true, this would be potential evidence that these differences are normal differences, not abnormalities. 

The borderline trait of hyper-reactivity often becomes maladaptive in non-family adult social situations because most other people do not react like the family members that produce offspring that show borderline traits.

Unfortunately, for reasons discussed elsewhere in this blog, patients with BPD usually look for people to hang out with that do in fact act like their family members, and, if the others do not act like that, often go out of their way to try to provoke them to react in these ways.

Error management theory may also explain something that psychologists call the fundamental attribution error. When observing the behavior of strangers, we are all more likely to attribute their behavior to the person’s underlying dispositions to a greater extent than is logically warranted. We all err on the side of thinking that their behavior is due to their innate tendencies rather than it being a reasonable reaction to the particular environmental situation in which they find themselves. This social judgment, wrong though it often is, helps us to avoid connecting with poor social partners.

So, is it better to be paranoid or to be optimistic? It all depends on our experiences over a lifetime. Due to natural selection, the truth of any particular judgment is far less important to us than its potential effects on our survival and reproductive success.