Irrational Beliefs vs. Defense Mechanisms

The current predominant school of thought in psychotherapy is called cognitive behavioral therapy (CBT), which replaced the previously dominant school of thought, psychoanalysis (PA). There are of course, other psychotherapy schools - over 200 of them as a matter of fact. Why? Well, as I described in a another post, because of three facts: 

1. The brain is so complicated. 
2. We can’t read minds. 
3. People lie not only to others but themselves. 

Psychology is still a very young science. 

It is in a phase of development that the scientific philosopher Thomas Kuhn, in his classic book The Structure ofScientific Revolutions, called the “pre-paradigmatic stage.” This means that in young sciences in which not a lot is known, a lot of theories compete with one another for dominance until the evidence accumulates to the point in which one model starts to predominate. After a while, some problems with that model arise, which then leads to the development of new models. For instance, although Newtonian physics still works for large objects, it falls apart at the subatomic level, where it has been replaced with quantum physics.

Understanding that this is the way science works has not stopped a lot of psychologists and other therapists from loudly claiming that their model is the only correct one. The psychoanalysts used to do it. When anyone dared to question the theory, they were told they needed to get into psychoanalysis to find out why they were resistant to its ideas. Three logical fallacies in a single sentence! (For those readers interested in logic: ad hominem, non-sequitur, and begging the question. If you want more detail, e-mail me back channel).

Now the CBT people are playing this same “We are right and you are wrong; we are superior to everyone else” game. Historically, the game went down this way: Psychoanalysis attributed “neurotic” behavior (showing signs of mental disturbance but is not psychotic) to conflicts in individuals between their biological urges – their id – with their values that were internalized from their upbringing – the superego or conscience. CBT people said this was all a buncy of nonsense, and went on to cherry pick certain parts of PA theory that were obviously incorrect to throw hot water on all of the PA ideas – which is another one of the tricks that indicate “groupthink” is operating instead of “facts and logic.”

Which brings us to what is postulated to be the cause of neurotic behavior which cognitive therapists champion (behaviorism – rewards and punishments - seeming to have almost disappeared from the therapy arsenal of a lot of CBT therapists). Starting with Albert Ellis and latter with Aaron Beck, they attributed it to “irrational thoughts.” Someone thinking, for example, that they simply must be this or that, or torturing themselves by imagining unlikely worst-case scenario outcomes which would then prevent them from even trying something new that they might just excel at.

So who’s right? Well, both of them. But don’t tell that to any of them on either side. I once mentioned what I am about to say to Albert Ellis at a psychotherapy conference, and he practically laughed in my face in front of a whole audience. Anyway, the key is something that authors Jonathan Haidt and Gregg Henriques have discovered: Logic in human beings did not evolve to arrive at truths. It evolved to justify group norms. 

Groups have to stick together to survive; they can’t be constantly arguing about everyone’s individual ideas about what to do when they are, say, attacked by another tribe. So group cohesion has survival value – at least it used to. It still does to a significant extent, but with the advent of technology and other modern developments, not nearly as much as it once did.

Before I understood this, I was bothered by something I called the “problem of stupidity.” Why were people torturing themselves with these thoughts which are obviously and transparently stupid or illogical.  Even seemingly highly intelligent people do this all the time. Are we all really that dull-witted? I didn’t think so, so I asked myself why these people are seemingly acting as if they are that dumb.

See if you can spot the irrational idea in a recent letter (8/14/19) to advice columnist Dear Abby:

8/14/19. DEAR ABBY: I've been with my boyfriend, "Rocko," for two years, but in the late months of last year… He would disappear for days at a time, block my phone number and ignore me. I was sure he was seeing another woman or taking drugs because he is an ex-addict. Two months ago, he was arrested. I was right -- Rocko was on drugs and had been hanging out with another woman… I hate myself, and I can't stop wondering why I wasn't enough.

See it? Her boyfriend is an addict and a cheater, yet this woman wonders why SHE wasn’t enough for him! It wasn’t his glaring and obvious faults and limitations: his problems were all due to her and her being inadequate to meet all of his needs. How nice of her to blame his irresponsible behavior on herself rather than hold him accountable!

If we assume that she is not stupid enough to think this is a logical conclusion, then we have to ask ourselves why on earth she doesn’t just dump the S.O.B. and find someone who will treat her right. I answered this by looking at the end result – what I call the net effect  - of her continuing to think this way. It’s obvious. She ends up staying with a man who cheats and uses drugs. So this would have to be her intent.

(But why on earth should she want to do that? The answer to that question in my opinion lies in her playing some sort of dysfunctional role in her family of origin which requires her to do this in order to stabilize her unstable parents. Explaining that part is beyond the scope of this post, but various roles are discussed in detail in previous ones).

So the irrational belief generates anxiety which then prevents her from acting in her own best interests. This allows her to continue to sacrifice herself for her kin group – a process known in evolutionary biology as kin selection. Guess what? The defense mechanisms of PA accomplish the very same thing. Analysts think that defense mechanisms are meant to control anxiety, but as a fellow blogger known as The Last Psychiatrist once said, if that were true, they sure do a lousy job of doing that. No; in fact, they too are meant to either create anxiety or do other things which lead people to avoid doing something that might conflict with their role in their family.

If for example your role in your family is to be a scapegoat so that your frustrated father can blame you for all of his problems and not have to feel bad about himself, his behavior is bound to make you angry. Your anger makes it hard for you to maintain the scapegoat role. You may eat (or repress) a certain amount of it, but some of it must be discharged somehow. So you come home and kick the dog (the defense mechanism of displacement).

Defense mechanisms or irrational thoughts? You say tow-may-tow, and I say tow-mah-tow. They are the same damn thing!

Guest Post: My Experiences with Family Dysfunction and Therapists - Anonymous

Editor’s note: This guest post came in response to my request for stories from those on my Facebook  fan page who had a bad experience with therapists who seemed to think that all of their problems were in their heads (for example, poor distress tolerance, irrational thoughts, or anger issues) and had little to do with other people who were stressing them out or pissing them off.

When I was 6 or 7, a neighbor (age 17 or 18), took me into his house "to play a game." He blindfolded me, made me kneel, and took his penis out for me to suck. The blindfold wasn't properly attached so I was able to figure out what he was doing. Afterwards - and after the mandatory "don't tell anyone" - I told my grandma, who then informed my parents.

Now, my mom certainly has her own issues. She hates being touched, always tends to think only about herself, is obsessed with TV shows, tends to be depressed and spends most of her free time in her room, and has a very high fear of going to the doctor - even though she is one! My Dad was certainly narcissistic (as you'll see it in a minute), so they both decided it was best to sweep it under the rug.

Years later, when I was 12, I had my dad's brother pull me close while dancing in order to rub his large stomach against my budding breasts.  Thinking back, I later realized that my Dad never ever let me stay with my cousins. My mom then confirmed that his brother is a pedophile. His poor, poor stepdaughter from my aunt's previous relationship! My dad must've known this, yet when I was raped, his answer was...to become my rapist's godfather!!!

My dad - and mom - made me go to my rapist's Confirmation (a Catholic ritual for teens) a year after my rape. We remained neighbors, and my Dad had weekly breakfasts with that family. No, I am not kidding. When I was 8 or 9, my mom bought a house two doors down from my grandparents...but only she and my dad moved out. I was told to stay with my grandparents "because I would be more comfortable there, and we need money to build a second floor." They never did.

My Dad was never steadily employed. I caught him kissing the maid when I was almost 13. So my mom, who at that time was working in a different region, came back home and told him to get out. He then blamed me for the "breakup of our family." I was also sexually harassed several times as a teen, but I never told my mom or grandma because my grandma told me I was "dirty" because I was still talking and playing with that neighbor. Why would I stop? NO ONE bothered to explain that what had happened to me was sexual abuse.

My uncle on my mom’s side slapped me when I was 13 for defending his teen housekeeper, and my aunt and mom (after I had come back home) wept but said nothing. Again, no one talked to me about what had happened. My dad got cancer when I was 17 and I asked him to come home. His siblings were robbing him and not taking care of him. He initially rejected our offer. Only when he knew for certain that his siblings were taking important property deeds (he owned a house in the mountains. I am Peruvian), did he finally agreed to come back to be looked after by us. He was bitter and scared, but was still a bad parent. I had barely seen him during the 5 years that he was not living with me - his choice, of course. I again saw him flirting with the maid during his remission. He died when I was 22.

Although I've barely ever been beaten, and no one in the family did drugs or alcohol, I nonetheless had a highly traumatic childhood. I'm a Psychology student. I am a 4-time college dropout from 3 universities. I am married now and living in Europe. I have been subjected to verbal abuse at home, but he's getting treatment. I’ve been diagnosed with ADHD, but I’m wondering if it's the right diagnosis. I do acknowledge that a trial of Concerta did show me I can do more, although I stopped after 14 days because the side effects on my mood were too much for me.

With all of this, I have also been subjected to racism and homophobia in society. I'm not a lesbian, but I "look like one,” apparently because of my very short hair and baggy pants. Once,  when I had messy hair and not-fancy clothes, I had to leave a store because of a screaming security guard who was asking me what the hell was I doing at that store (I lived in a "well-to-do" neighborhood). Where I am, racism is expressed with frowning faces and rude attitudes from clerks. But when they see me with my White husband, I am "graciously welcomed" anywhere. I guess those two (racism and sexism) can never be escaped, but I am DAMNED sure happy I am far away from my family's dysfunction now.

At 22 I started psychoanalysis, and my therapist wanted me to focus on forgiving my parents.

Later, I did CBT, and that psychologist wanted me to focus on my goals, when all I could think of was how damaging the sexual abuse had been, and how troubled I felt about being neighbors with the rapist.

I don't know what kind of treatment I received from a third therapist I took on, but he said I should focus on why I went into the neighbor's house in the first place. That was said to mean that I was starving for male attention, and I was told I should work on that.

There was that psychiatrist too, when I was 26, who I told about my anxiety and possible ADHD, He said I should just take it easy, that no one is supposed to demand too much of themselves and that is okay not to accomplish everything I want. He added that it's all about "finding contentment." I felt that that one was sexist AND racist.

My parents and I went to ONE session of family therapy when I was 16, but as soon as the therapist pointed out to my parents their troublesome, inattentive behavior towards me, we stopped going.

So from my experience, what I learned is that even people with the best intentions (or at least who are supposed to have them) will try to redirect you to what they think it's best for you, instead of actually listening to you. Validate your own feelings, and after that, inform yourself  both about what psychology says about your own experiences AND about how to pick a good therapist. Work from there. Too many uninformed people will spout their opinions, whether they are family or professionals.

Another Pharma Trick for Overstating the Effectiveness of their Drugs: The Will Rogers Phenomenon

Will Rogers

Big Pharma has a number of ways, many of which have been described in this blog, of making their drugs look a lot better than they actually are. And some psychotherapy researchers use the techniques to push their favored school of thought. I recently came across another one of which I wasn’t aware. 

It is easiest to see with drugs used for cancer chemotherapy, but can be applied in other cases.

It is called the Will Rogers phenomenon (and is also called Stage Migration). It is an apparent epidemiological paradox. The Rogers reference comes from a remark made by the famed humorist Will Rogers about migration during the American economic depression of the 1930's: "When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states."

With cancer drugs, it comes from changes over time in the way the severity of the disease is assigned to patients - how the various stages of a disease are determined in each case. (Stage I is when the cancer is smallest, has not spread, and is usually the most easily treated. Stage IV is the most advanced with metastases). The issue comes about because the technology for staging a cancer in a given patient has improved significantly. This can produce spurious improvements in stage-specific prognosis, even though the outcome of individual patients has not changed.

New imaging tools have allowed detection of cancer metastases before they became evident clinically. As a result, more patients are classified into the more severe metastatic disease stage from the less severe single tumor stage. Such a 'stage migration' resulted in an improved survival of patients in both the less and the more severe disease stages. (Multiple sclerosis is another disease where this sort of thing has taken place).

Some studies compare a new treatment to the treatment of so-called historical controls who had received other treatments. This is usually done because carrying out placebo-controlled studies in potentially dying patients is unethical. The Will Rogers phenomenon is recognized as one of the most important biases limiting the use of historical controls groups in experimental treatment trials. 

Essentially, the use of different diagnostic criteria may generate spurious improvements in the medium-term prognosis which then may be wrongly interpreted as treatment effects.

In psychiatry and psychology, placebo controlled studies can be done ethically, but a variation of the Will Rogers phenomenon can still take place because of how rigorously DSM diagnostic processes are applied to patients. When I first started training, the criteria for major depression and mania were rigorously applied in treatment studies; now they are often applied sloppily – on purpose. 

Chronic unhappiness, which may respond very well to cognitive behavioral psychotherapy, is often now misdiagnosed as the more serious major depressive disorder. If you have a bunch of those folks in your psychotherapy outcome study, CBT can be “shown” to be effective in major depression by including people in your study who really don’t have major depression.

The more serious depressions respond better to antidepressant medications. Since most antidepressants are now generic, drug companies who want doctors to use other, more profitable drugs like Latuda can do the same thing to “show” that antidepressants are actually less effective than they actually are. Placebo response rates in antidepressant studies have gone up about 10% every decade, and this is what I believe to be the reason.

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.

Invalidating Therapists Act Like Job's Counselors

Recently I heard a story about a man who made a choice regarding his career that was at odds with family expectations. He was roundly criticized by his father, some of his siblings, as well as an uncle.

Much later, when the man started having financial problems, these relatives told him immediately that this was all his fault. According to them, his financial woes just had to be because of the career decision he had made.

This is an example of what I refer to as clustering - family members ganging up on one of the members for breaking a family rule, and pressuring him or her to tow the party line.

In an analogous fashion, some therapists inadvertently feed into a patient's problems rather than help remedy them, and in the process invalidate their own patients. Before getting to that, however, I wanted to mention that the man in question likened his relatives to "Job's Counselors." I of course had heard the story of Job, but I had never heard about that part.

As most readers will know, the Book of Job in the Bible describes the tale of a pious and righteous man named Job, who had considerable wealth as well as wonderful sons and daughters. In heaven, God asks Satan for his opinion of Job's piety. Satan answers that Job is pious only because God has blessed him; if God were to take away everything that Job had, then he would surely curse God.

God then gives Satan permission to take Job's wealth and kill all of his children and servants. Still, Job continues to praise God. Then, God allows Satan to afflict his body with boils; still he remains pious.

Three of Job's friends became known as "Job's Counselors:"  Eliphaz, Bildad, and Zophar. The friends tell Job that his suffering simply must be a punishment for sin, for God causes no one to suffer innocently. This of course, is the exact opposite of the truth as laid down in the story.

So how does this relate to therapists inadvertently invalidating their patients? Well, many therapists focus on alleged defects in their patients and work on such things as "anger management," "distress tolerance skills," or fixing the patient's defective "mentalization" (the ability to accurately assess the intentions of other people). 

These sorts of interventions presume that if someone is upset, angry, or unhappy with the way the world is treating them, then therefore there must be something wrong with them. Even when they are in fact being abused horribly!

Now, in defense of therapists who received reductionistic training, it is true that patients often act as if there is something wrong with them in these sorts of areas. However, as I have discussed in previous posts, there is a big difference in patients' public performance at a task as opposed to what they are capable of doing.

Often the alleged defects are in reality part of one of the dysfunctional family roles frequently described in this blog. People who are exclusively trained in CBT do not know about —or if they do they do not accept—the concept of a persona or false self. CBT made a name for itself by attacking psychoanalysis, its predecessor as the predominant form of therapy, and rejected all of its concepts regardless of whether they were right or wrong.

Researchers in personality disorders routinely make this same logical error all the time in studies. They look at the subjects' reactions without looking at all at what they are reacting to! It is a bit like watching a movie in which all but one of the characters - both their behavior and their verbalizations - are redacted so that the viewer can only see what one character is doing and saying, apparently in a vacuum. And then asking the viewer to guess why the one remaining character talks and acts the way he does.

An excellent example of precisely this appeared in the February 2016 issue of the Journal of Personality Disorders - a study called "Using Negative Emotions to Trace the Experience of Borderline Personality Pathology" by M. Law and others. Research subjects were asked to record their emotions (especially irritability, anger, shame and guilt) five times a day for two weeks, but not the environmental triggers which seemed to create these feelings. 

The authors came to the shocking conclusion that the subject's BPD symptoms and their negative emotions were intricately related. No sh*t, Sherlock.

Wouldn't it have been just a little more informative to have gotten data that would help us understand what sorts of situations were most likely to trigger both the negative emotions and the symptoms of people with borderline traits? Ya think?

Research In Psychotherapy: Outcome Research Versus Process Research

In my Psychology Today blogpost about research in psychotherapy outcomes, and in my last book, I complained about the inflated claims of researchers in psychotherapy - particularly those made by purveyors of cognitive-behavioral therapy (CBT). They grossly overstate both the power and the significance of their results.

Unfortunately, a new report by the Institute of Medicine (IOM) falls for this baloney hook, line and sinker. The report on psychosocial interventions for mental illness and substance abuse has drawn a wide variety of responses from the field - including praise, recommendations for improvement, and some sharp criticism from psychiatrists and mental health professionals who are experts on psychotherapy. I am obviously sympathetic to the critics.

Of particular interest is that the report lauds the so-called "evidence-based psychotherapies" - code for those therapies which are "supported" by the incredibly weak psychotherapy outcome studies. One critic, Peter Roy-Byrne, M.D, summed up the criticisms of the report as follows:" In medicine, there is usually an array of different treatments for the same condition because of individual variability that is still poorly understood. Yet the field of medicine does not spend its time trying to understand what are the common elements between various effective treatments, though it will often explore comparative effectiveness as a way of improving care. It may well be that different kinds of individuals and problems demand different psychotherapeutic approaches rather than that there is one elemental Holy Grail that will be best for everyone.”

Of note is that, at least if you believe in free will as I do, patients always can choose to either respond favorably or unfavorably to any intervention a therapist makes. It is just not all that predictable, because everyone can choose to respond differently. In fact, the very same intervention given to seemingly very similar patients can lead to responses that are completely opposite from each other - in one case the patient improves on some dimension, while in the next the patient may get worse! In psychotherapy, patients are very different from one another in ways that vastly outnumber individual differences that affect treatment outcomes in any other field of medicine.

Holly Swartz, M.D., of the Department of Psychiatry at the University of Pittsburgh School of Medicine, brings up another criticism of the IOM report: “The recommendation to reduce highly complex interventions to their component parts, however, is misguided. A bias toward CBT and CBT-based interventions constitutes an essential flaw in the IOM report, placing affect-focused therapies such as IPT (interpersonal therapy) at risk for unfair negative evaluation and, ultimately, elimination from our therapeutic armamentarium. … [T]he IOM report should advance an inclusive research agenda that reflects and supports the diversity of psychosocial interventions that the IOM purports to represent.”

Yet another problem with the IOM report and similar viewpoints is that they completely ignore the fact that there is a vast literature within psychotherapy research that does not focus on outcomes but on process. Process research looks at the moment to moment interactions of patients and therapists within the context of their particular relationship.

As Les Greenberg, Ph.D, puts it, "Research on change processes is needed to help explain how psychotherapy produces change. To explain processes of change it will be important to measure three types of outcomes—immediate, intermediate, and final—and three levels of process—speech act, episode, and relationship. Emphasis will need to be placed on specifying different types of in-session change episodes and the intermediate outcomes they produce. The assumption that all processes have the same meaning (regardless of context) needs to be dropped, and a context-sensitive process research needs to be developed. Speech acts need to be viewed in the context of the types of episodes in which they occur, and episodes need to be viewed in the context of the type of relationship in which they occur.

Speech acts refers to the fact that speech does not merely convey information to, or exchange propositions with, a listener. Sentences do things that are frequently independent of the meaning of the actual words that are used. Speech causes others to perform acts. If I say, "I hear you're having a party Saturday," I am not describing only my recent experience of having heard about the party. I am probably fishing for an actual invitation. In all likelihood, I have made in advance a determination that this sort of statement is the best way to accomplish my goal of attend­ing the party. I have made a prediction about the future behavior of the listener. If this particular ploy leads to no response or a different response, I will consider alternative strategies.

Those who tout psychotherapy outcome studies, which study psychotherapy interventions as if they occurred in some sort of relationship vacuum devoid of context, seem to want to pretend that the highly significant process research literature does not even exist. In fact, the vast majority of articles published in the journal Psychiatric Research are process studies, not outcome studies.

Groupthink: How Even Scientists Con Themselves in Order to Fit In

australianclimatemadness.com

In his brilliant book, The Righteous Mind, Jonathan Haidt argues convincingly that logic evolved in humans not to establish the truth about the world or to establish facts, but to argue for ideas that benefit the kin and ethnic groups to which we belong, as well as to maintain a good reputation within those groups. My colleague Gregg Henriques calls this the Justification Hypothesis: logic is used to justify our group norms.

Many of our beliefs are based not on facts or reason at all and in fact seem to be impervious to them. They are instead based upon either our groupishness (the opposite of selfishness). For almost all of us, it is generally more important for us to look right than to be right.

This type of reasoning appears at the level of the individual, where it is called defense mechanisms and irrational beliefs. It appears at the level of the family or kin group, where it is called family myths. It also exists at the level of cultural groups, where it is called theology. Or if it is not your particular brand of theology, then it is called mythology.

Another name for this phenomenon in general is groupthink. We cede the right to think for ourselves for the sake of our group, and we often try to discourage our intimates from thinking for themselves for the same reason.

Even scientists are not immune. So what are some of the mechanisms by which they do this to themselves and to other people? That is the topic of this post.

First, a brief review of some previous posts. As I described in one post, I realized a long time ago that the so-called defense mechanisms discussed by the Freudians and the irrational thoughts catalogued by cognitive therapists (CBT) had a purpose that was not only intra-psychic but interpersonal as well. 

Defense mechanisms are defined as mental processes initiated, typically subconsciously, to avoid ideas or impulses that are unacceptable to our value system, and to avoid anxiety. Another name for this is mortification. We may, for example, compulsively try to act in the opposite way that the unacceptable impulse would dictate (reaction formation), or displace our anger from one person onto another, safer one.

Their interpersonal purpose is to screen out beliefs and impulses that are threatening to the kin group, which is also why they are threatening to the individual within the kin group.

The irrational thoughts of CBT, which they attributed to humans being basically irrational, also functioned much like the defense mechanisms. If you, for example, "catastrophize" about what might happen if you indulged an impulse that your kin group does not approve of (by, say imagining the worst possible outcome of doing so), you will indeed scare yourself away from engaging in it. (Of course, the CBT folks reject the whole concept of defense mechanisms - I recall a somewhat sarcastic reply from cognitive therapy pioneer Albert Ellis when I brought this up at one of his talks).

On a related note, there are the logical fallacies that are enumerated by logicians and which are well known to members of college debate squads. An example is post hoc reasoning, which assumes wrongly that if event A is quickly followed by event B, then it is true that A caused B. I saw patients engage in many of these fallacies when confronted with the negative consequences of the behavior that seemed to be demanded of them by their families. So, I believe, the logical fallacies can also be used as defense mechanisms - specifically designed to avoid troublesome questions about cherished beliefs that on the surface are simplistic at best and preposterous at worst.

As mentioned above, scientists are not immune from groupthink and groupishness. In fact, they are as nearly as likely as anyone else to employ them. I witnessed many times in scientific debates how the debaters would subtly employ various techniques and mind tricks to silence critics of their studies or ideas.

A few examples among many:

a) Black-and-white, or all-or-none thinking. Biological psychiatrists seem to think that everything in the DSM diagnostic manual is a brain disease, whereas the anti-psychiatry folks believe that nothing is, and the listed diagnoses are all just alternate lifestyles, different ways of looking at the world, or reactions to trauma.

b) Arguments that advance the idea that, because many parts of the thinking of someone like, for instance, Freud, were totally off-base (like "penis envy" and his theories about homosexuality), that therefore ALL of his ideas were wrong (including such obviously real things as intra-psychic conflict and defense mechanisms).

c) Stating facts about the results of studies without describing certain contextual elements that put those facts in a different light. A great example I have already blogged about is how the leader of the National Institute on Drug Abuse spoke about experiments with monkeys showing them pulling a level to get cocaine until they died - while neglecting to mention that the animals were in solitary confinement with nothing else to do. When that was not the case, they behaved very differently.

d) Conflating the issue of how a phenomenon arises or what it means in the scheme of things with the issue of whether the phenomenon even exists at all. For example, CBT'ers would deny that the concept of resistance, a psychoanalytic idea that states that people are often highly invested in their psychological symptoms and resist change - is a real phenomenon. All the while, they failed to report in their case studies the high level of non-compliance with CBT homework assignments by their patients in treatment.

e) Grossly exaggerating the strength of certain research findings while completely ignoring the study's weaknesses and problematic assumptions.

f) Conflating another scientist's conclusion about the significance of a clinical anecdote with the description of the anecdote, and not considering what else the anecdote might mean.

g) Scientism: the idea that randomized placebo-controlled studies of something are the end-all and be-all of science, and that everything else is just anecdotal and not science at all. I answer those who make this argument by asking for volunteers for a randomized placebo-controlled study on whether parachutes reduce the incidence of deaths and injuries during falls from airplane flights. 

I also point out that scientism creates a problem when it is only a slight exaggeration to say that in order to study an important psychological phenomenon like self-deception with a large enough study sample and within a reasonable time frame, you would pretty much have to ask people about their opinion of themselves. Sorta defeats the goal of the study, doesn't it? So does this mean that therefore studying self-deception should be completely off limits to scientists? 

Scientists will often accuse other scientists of doing these things while doing them themselves. This is projection - another defense mechanism. These mental mechanisms are so pervasive in human beings that we are quite likely to find at least some of them in any scientific discussion. 

Discerning readers will no doubt find examples in which I do some of it in my posts on my blogs. 

Whatever Happened to Assertiveness Training?

My fellow blogger over at BehaveNet had an interesting entry on 4/23 that described an experience with a consultant who came to talk to a psychiatric hospital staff on the topic of "physician burnout." The consultant suggested that the psychiatric staff consider using mindfulness techniques to basically chill out about all the stresses under which they have been working.

In the mindfulness post that I wrote, which is linked above, I opined that so-called mindfulness techniques can be quite helpful under certain types of circumstances. Most important, they can help one stay relaxed and clear-headed when being subjected to environmental stressors that fall mainly into two categories: 1. Common, everyday types of stresses due to the vicissitudes of life that change from day to day and that almost all of us experience, or, 2. Those stressful environmental contingencies over which one has zero hope of changing or correcting. (Mindfulness techniques can also help one stay more relaxed when tackling situations that need to be changed or corrected).

The stresses that lead to physician burnout may not fall into one of these two categories. In fact, one of the most common causes is managed care insurance companies and business types with no medical or psychiatric expertise who are constantly telling doctors what they can or cannot do, and making their professional lives miserable. 

What this consultant seemed to be recommending was using mindfulness techniques as a means of employing something that is definitely not called for in this type of situation: passivity. 

Insurance companies and business people need us doctors more than we need them. We should be doing whatever we can to get them out of the way of effective patient treatment as well as to stop them from preventing us from having a normal and balanced work/life schedule.

The BehaveNet blogger hit the nail on the head: "Dr. Meredith's prescription of mindfulness to address the problem suggests to me a strategy to get physicians to devote adequate time to contemplation of our navels so we will learn to tolerate even more abuse and exploitation with a smile and a "Yessuh, Massah." The blogger suggests that instead doctors push back, refuse, resign, set limits, make demands, and maybe even disrupt things.

This recommendation should also be applied to what psychotherapists do with their patients.

There is unfortunately a current psychotherapy craze of teaching mindfulness techniques to help patients with major family issues to learn to tolerate their stressful family and relationship lives with more equanimity. This is crazy. Not to mention invalidating to patients, as it seems to imply that the problem resides entirely with them. Instead, therapists should be inspiring them, and teaching them how, to fix the situations that are creating their stress in the first place.

I am not saying that the patients' own behavior does not contribute to the dysfunctional family patterns of which they are a part. Clearly it does. But that just means they have to change their own behavior in reaction to the abuse, distancing, and double messages which they receive on a daily basis from their family system members. Doing so is in fact a good strategy for stopping these patterns, not merely tolerating them better.

Cognitive behavior (CBT) therapists have become the biggest champions of using mindfulness techniques for patients with these personality/family problems. This is ironic because back in the 1970's those very same CBT therapists were the very ones who labeled being passive a form of psychopathology! As also mentioned in the BehaveNet blog post, they used to advocate something called assertiveness training.

Basically, in response to mistreatment, assertiveness training theory described one helpful general pattern of responding and three dysfunctional ones. The dysfunctional ones were labeled passive (just sit there, take it, and do nothing about it), aggressive (attack the other person verbally or even physically to impose your will on them), and passive-aggressive (mad at your husband? Burn his toast).

The healthy response was called assertiveness - that meant speaking up for yourself and demanding respect without trying to bring the other person down, disrespecting their needs and viewpoints, casting aspersions on them, or in any way attacking them.

After a period of teaching assertiveness skills to their patients, CBT therapists began to back down from it little by little. They were later forced to admit that the "healthy" responses they taught might get someone beat up or killed in some situations, so it might be best to let some things go.  If you speak up when someone butts in front of you in line these days, the other person may go ballistic and hit you or even pull out a gun. Thankfully this does not happen very often if one is not aggressive, but it is a risk.

Additionally and gradually, the CBT therapists began to fall into the trap of thinking that everyone's problems are all just in their heads. Just like the psychoanalysts they replaced. Last, when it came to intractable family dysfunction, assertiveness skills just did not seem to work all that well anyway.

I have found that with ongoing repetitive family problems, the sort of generic assertiveness skills taught by CBT therapists in fact do not work. That is because family members have developed a whole repertoire of counter-moves that scream to the member attempting to be assertive, "You are wrong, change back." Some of these counter-moves are quite frightening - I described many in a previous post. All involve the person who is trying to be assertive being invalidated in some way and made to feel small for daring to speak up.

This hardly means, however, that the proper strategy for handling these problems is passivity. What I discovered is that the assertiveness training techniques that used to be taught had to be modified to fit the sensitivities and histories of each of the other family members being addressed. These modifications were different for every family, and they had to be tailored specifically to each one. No "one size fits all" here. 

Furthermore, there is no way to know in advance which strategy might work best in a given context, but there was almost always one that could be devised that could help diffuse the family drama significantly for any patient.

I discussed many different strategies in my series of posts in this blog on How to Disarm a Borderline and in another series entitled Ve have Vays of Making You Talk.

So, the CBT therapists had the right idea about assertiveness training before they kinda gave up on it and resorted to the "distress tolerance skills" that are actually part and parcel of what they used to label dysfunctional passivity. They instead should have listened to some of the ideas from family systems therapists in order to improve their therapeutic techniques. 

Mindful passivity? Plenty of time for that at a certain point in the future. As the lyrics from an old song by "Weird Al" Yankovic that used to be played by satirical disc jockey Dr. Demento proclaimed, "I'll be mellow when I'm dead."