The Shrink Tank

Aggressive Athletes: Out of Control and Unapologetic

Jared DeFife, Ph.D. — Thu, 19 Nov 2009 07:01:48 +0000

"It is wise to direct your anger towards problems -- not people; to focus your energies on answers -- not excuses." -William Arthur Ward

Recently, University of New Mexico soccer player Elizabeth Lambert was called out by ESPN for punching, kicking, shoving, and throwing elbows against opponents after her team fell behind in a conference tournament game. In her most blatant attack, she yanked back an opponent's ponytail, ripping her to the ground.

News coverage of these incidents follows a time-worn pattern: the highlight reels run, the sports talk jockeys express outrage, the player makes a media apology, the commissioner steps in to deliver a light sentencing, pundits debate whether the punishment was severe enough, the player eventually returns to business as usual, and the video clip lives on in infamy through endless replays on YouTube.

Tuesday, the New York Times published Elizabeth Lambert's apology and an attempt to put her actions "in context". Not surprisingly, the apology seemed scripted, hollow, insincere, and devoid of genuine remorse. After expressing her deep and lasting regret over the incident, she immediately launches into some very familiar externalization and blame refrains:

She distances herself from the actions: "That is not me"... "That's not the type of player I am". Except for the fact that it WAS her, because who else was it? And it's EXACTLY the type of player she is, because that's how she played. She carried on this conduct throughout an entire half of play. She received a yellow card for aggressive play in each of her prior two games.

She minimizes and writes off the context of the situation: "It's a game. Sports are physical." Sure, sports are physical and aggressive. But there are a ton of games played without inappropriately violent incidents. How many times do you see a player whipped to the ground by her hair?

She blames opposing fans and aggressive opponents. She blames the refs for not throwing more yellow and red cards.

And not surprisingly, she blames the media. "I think the way the video came out, it did make me look like a monster." Really? Did James Cameron come in and drop some CGI effects on the video? She goes on: "I definitely feel because I am a female it did bring about a lot more attention than if a male were to do it. It's more expected for men to go out there and be rough." Really?!?! Last time I checked, male players face similar media scrutiny for similar incidents. Anybody ever heard of Ron Artest? What about Oregon running back LeGarrette Blount, who was suspended for sucker punching linebacker Byron Hout after a loss to Boise State? Or Florida linebacker Brandon Spikes, who was blasted in the media and suspended after attempting to gouge the eyes of a Georgia opponent during a pile-up? And then there's wide receiver Braylon Edwards, who in the hours following a particularly poor performance for the Cleveland Browns was arrested for assault after he sucker punched a 130-lb friend of Cleveland sports superstar LeBron James.

It looks like rage in sports is, well, all the rage. So why is every one so angry? Impulsive acts of rage and aggression often emerge following threats to an overinflated and unstable sense of self-worth. Interestingly, the same people with excessive confidence in their talents and abilities can also be incredibly insecure. This kind of fragile egotism is common in sports, especially on the national stage. While sports promote self-respect, team cooperation, and respectful competition, they also fuel pride, fierce individualism, and aggression. Athletes work hard, are driven to win, and are rewarded with fans and fame. At the same time, their image and respect can turn on a dime. Athletes are often judged to be only as good as their last game. Fans and media can shift loyalties in a heartbeat. A poor performance, a lost game, or a losing season can cause a serious blow to the ego, and some people react to these slights with impulsive and explosive rage.

Psychoanalyst Heinz Kohut defined the phenomenon as narcissistic rage. In his book Evil: Inside Human Violence and Cruelty, social psychologist (and PT blogger) Roy Baumeister describes it as threatened egotism. From both clinical and experimental observations, it becomes apparent that the most hostile and aggressive individuals are ones with high, but unstable, self-esteem. Baumeister writes: "These people think well of themselves in general, but their self-esteem fluctuates. They are especially prone to react defensively to ego threats, and they are also more prone to hostility, anger, and aggression than other people". Clinically, it's an extremely difficult dynamic to treat. Fragile egotists rarely take accountability for their actions, constantly blame others, feel like victimized outsiders or outcasts, and react with aggression at any suggestion that they may have some psychological shortcoming.

If Elizabeth Lambert is to blame anything, it should be her own arrogance and insecurity. Indeed, the New York Times article notes that she has often struggled with low self-confidence and uncertainty about her abilities to play at an elite competitive level. It's hard to lose. It undermines all the hard-work it takes to be successful and the pride we take in our talents and accomplishments. We all do things in the heat of the moment that can be hurtful, disrespectful, and regrettable; let ye among us without sin cast the first stone. But the mark of maturity is revealed in how one responds to and grows from such experiences. Character develops from focusing our energies on answers-not excuses.

The NSA suspects that you're a terrorist: How the Bush administration implemented unprecedented domestic wiretapping programs

Jared DeFife, Ph.D. — Sat, 11 Jul 2009 22:21:18 +0000

"The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized." -The Fourth Amendment of the United States Constitution

Late last night, a report was released about the Congressional investigation of unprecedented domestic spying and wiretapping programs secretly implemented by the Bush administration in the aftermath of the 9/11 attacks. For any human being concerned about privacy, information security, U.S. history and constitutional law, the revelations are hair raising.

One of the cardinal virtues of a psychotherapist is privacy. We have a duty and an ethical responsibility to safeguard the private information revealed to us in our practices. There are a certain limitations to a blanket level of secrecy (signed release from a patient, court order of records, disguising identity in conversations for teaching/training/supervision, co-ordination with health care providers during a life-threatening emergency, and the duty to warn appropriate authorities when we have information that a patient proposes an imminent threat of harm to self or others). But generally, what happens in therapy, stays in therapy. Just like Vegas...

...except that just before January 2004, what happened in Vegas did NOT stay in Vegas.

In mid-2007, FRONTLINE aired a program titled "Spying on the home front". The program is available to view free online, and I highly recommend watching it. The report detailed how the Bush administration yielded unprecedented executive authority to obtain warrantless collection of intelligence information without due process about American citizens with no probable cause for criminal activity. For example, following a hunch on same vague chatter about Al-Qaeda having "a possible interest" in Las Vegas in for the 2004 New Year's celebration, the FBI confiscated hotel, airline, rental car, casinos and more on every single person who visited Vegas at the time. Were you visiting then? The FBI had your number.

The Congressional report issued last night revealed that wiretapping and datamining programs such as this were extensive, were carried out without Congressional oversight at the National Security Agency, were drafted through the White House Office of Legal Counsel (with Justice Department lawyer John Yoo overwriting more Constitutional law than a whole bench full of "activist" supreme court justices), and were not effective in yielding actionable intelligence.

Again, I'd urge you to check out the Frontline report (Frontline yielded some incredibly fascinating and informative programming during the end years of the Bush administration), but here's an abbreviated tour through the history of Government privacy protections:

Let's have a tea party!

Way back around the 1750s...like way back before they had iPhones and people mostly had to use Walkmens and stuff...the British monarch King George II had a habit of writing orders to have his lackeys poke into your stuff to try and get more tax money off you and maybe even take some of your stuff away if you didn't pay that money. But then the King died and his grandson King George III had to re-sign those orders or else they would expire. A few folks had a problem with this (I think they didn't want officers checking under their white wigs or something) and made a law to ban the king's direct orders unless a judge or legal authority decided that there was a good legal reason for these searches and seizures. That law was overturned, however, because it's good to be the King, and if King George, who was quite the decider, says so...it must be done.

Around then, a lot of people in Boston started to get a little cranky (maybe the weather was bad...it was getting closer to winter...in Boston!). They weren't thrilled with George III's grand-daddy George II, but this George III was just unbearable. Even though these Bostonians were angrier than when the Yankees are in town, they were still civilized folk. So they banded together in general bonhomie, and threw themselves a nice Tea Party. A few years later, they wrote up this set of laws called a Constitution...(writing laws was how they told other people about stuff before blogs, facebook, and twitter) including the Fourth Amendment which went along the effects of "thou shalt not search for, nor drink my beer without proper legal recourse, and if thou is allowest access to said beer, only for a specific and limited amount of time".

The gambler who used pay phones (because they're kinda like slot machines)

Almost 200 years later (but still before YouTube!), a guy named Charles Katz of California was arrested for illegal gambling. His Blackberry Storm must not have been working because he used a pay phone to place bets across the country (some of those bets were in Boston...shout out to Beantown again!). The FBI had used wiretaps on those phone booth calls as evidence to arrest him. In Katz v. United States 1967, the Supreme Court overturned Katz's conviction on the ground that the FBI wiretaps constituted illegal search and seizure.

The justices made three major points: the fourth amendment covers a "reasonable expectation of privacy"; the fourth amendment protects the privacy of people and not places so your electronic communication is protected; and that warrants must be obtained for wiretapping or search/seizure which are sufficiently limited in scope or duration.

Nixon was just trying to get a Frosty and cheeseburger from Watergate

Then there was this guy Richard Nixon, who became President of the United States. He was kind of a paranoid sort, always worried that people were out to get him. He was a guy who wanted to keep his friends close and keep a close ear on his enemies. Of course, he believed that many of his enemies weren't just foreign powers, but people actually living inside the United States. He made a lot of tape recordings and had the CIA and FBI do a lot of spying etc., etc. It turns out that Nixon's room service at the Watergate hotel was not very good, so the Senate opened up the Church Committee (led by Sen. Frank Church) to investigate the CIA's and FBI's intelligence gathering methods. The then director of the CIA, William Colby, was brought in to testify about CIA activities in front of Congress. Colby felt that the CIA should be accountable to the legislative branch, even though a number of former Nixon staff tried to block his testimony. Donald Rumsfeld, not surprisingly, was one of these players trying to keep Congress out of the President's business.

The Church committee decided that the U.S. needs to have security on two fronts. First, we need to be safe from foreign powers and enemies, some of whom have agents in the U.S. Second, we need to be safe from ourselves; we can't sacrifice too many of our own personal freedoms under the banner of homeland security. To hold this difficult balance, the Foreign Intelligence Surveillance Act (FISA) was created. Also, William Colby was replaced as head of the CIA by....George H.W. Bush.

If you thought your VISA terms were complicated, wait until you see FISA

FISA created a "secret court"...sort of like you did in that backyard clubhouse with your friends as a kid. This secret FISA court makes rulings about whether or not the U.S. is authorized to conduct surveillance on foreign enemies both abroad and in the U.S. Since we are on the web here, let's talk about electronic surveillance...this means phone calls, emails, electronic records, etc. The terms have many different scenarios built in, but the main thrust of the FISA code is that the President may authorize warrantless electronic surveillance for the period of up to one year if it is certified by the Attorney General, if the surveilled is directly related to a foreign power, and IF "there is no substantial likelihood that the surveillance will acquire the contents of any communication to which a United States person is a party", or it is only for the first fifteen days of a war declared by Congress. Otherwise, the FISA court must issue a warrant for such surveillance.

When all is said and done, United States law seems to spell out that a sustained blanket surveillance of United States citizens' electronic communication without a court order is a violation of Fourth Amendment rights.

Then came George the Fourth

After 9/11/01, United States government philosophy changed drastically. Essentially, the US adapted an act first, ask later stance. We went from due process trials to enemy combatant prisons. We went from prosecuting crimes to trying to prevent them. From defense to pre-emptive strike. Our goal became to "stop this from ever happening again". Trauma creates hypervigilance. After a traumatic event, people try to observe and control their circumstances to prevent from ever being harmed again. But we cannot constantly prevent all harm, and eventually this intensely active vigilance fueled by traumatic anxiety fries neurons and saps energy, leaving one more vulnerable to attack than ever before...and thus trauma cycles on.

As exemplar, on December 16 2005, the New York Times reported:

"Months after the Sept. 11 attacks, President Bush secretly authorized the National Security Agency to eavesdrop on Americans and others inside the United States to search for evidence of terrorist activity without the court-approved warrants ordinarily required for domestic spying, according to government officials."

From yesterday's report we learned that those eavesdropping programs were widescale, had little oversight, and were of little value in preventing terrorist activities.

Paul Wachtel is a psychologist who describes mental illness as a cyclical psychodynamic pattern that is maintained through anxiety. In essence, people are often tragic figures who serve as their own worst enemies. For example, a man so afraid of being left by his romantic partner excessively seeks reassurance, becomes depressed at any separations, and is jealous of time spent apart. Such a person is hardly a great boyfriend, his overbearance leading his loved one to pull away. Her withdrawal raises his anxiety and fuels a vicious cycle of greater anxiety, rejection and abandonment. Shakespeare's work is famous for writing these kind of tragic characters as seen in public figures and political leaders....King Lear, Richard III, Othello, Julius Caesar.

This country's greatness is founded on a set of precious freedoms from tyranny and oppression. In the methods we seek to maintain these freedoms as a country, we must not become the tyrannical, intrusive, and oppressive enemies of ourselves.

--------------------------------

Comment below or email correspondence to jareddefifept@gmail.com

Diversity in Entertainment - Why it Matters

Jared DeFife, Ph.D. — Tue, 30 Jun 2009 04:35:53 +0000

"Nothing is ever so wrong in this world that a sensible woman can't set it right in the course of an afternoon." -Jean Giraudoux, The Madwoman of Chaillot

Recently, I wrote about an NPR.org posting by Linda Holmes on her blog, Monkey See. Her post, entitled "Dear Pixar, From All The Girls With Band-Aids On Their Knees" is an open letter to Pixar in praise of their films, but also identifying the lack of a single female lead character in any of their ten (plus two more in the works) films. This would seem to be a significant phenomenon given that females comprise about one half of the world's population. Imagine flipping a coin twelve times and have heads come up each time. Better yet, imagine the sheer impossibility of the American League team winning Major League Baseball's All-Star game 12 straight times! Oh...wait.

In my post, I noted that the lack of quality female leading roles in films was more likely a problem of supply than of demand, given that about 90% of mainstream American movies are directed by men, not to mention all the male screenwriters and producers out there.

This elicited a number of reader comments, which is great, as one of my favorite parts of blogging is seeing the range of reader responses (so keep ‘em coming!). I wanted to take a moment to respond to those comments, and clarify a few thoughts of my own.

Yeah, but there's that one show...
A few commenters were able to name some TV shows with female lead characters...Disney's Kim Possible, Nick's Dora the Explorer, and Fox's The Sarah Connor Chronicles. This is a common response when a population trend is identified which challenges our belief systems, creating what we shrinks call cognitive dissonance. To reduce this uncomfortable psychic state, we often point to a single exception as if it negates the argument. Stephen Colbert has parodied this brilliantly when he rolls out a picture of him with his "black friend, Alan" to defend any implications of him being prejudiced. "I don't see color", he says. Having grown up in Ohio, my school system was hardly the model of cultural diversity, despite rather large class sizes. We used to joke that like in South Park, we had our one Jewish friend. Yet one would hardly claim that my high school was practically a kibbutz. By the time I went to grad school on Long Island in psychology, the tables were quite turned and my religious upbringing was in the significant minority, a fact joyously skewered in a comedy skit we created called "Jew Crew for the Goy Boy". Just because we can name a few shows or movies with females in the lead does not equal equivalent gender representativeness in films.

What's with you quota quacks, anyway?
Bob wrote, "I find the idea that we ‘need' more female lead characters to be sexist. Are girls so in need of fictional role models that writers have a social obligation to provide them?" A few other voices joined his concerns about placing social obligations on creative professionals. No one likes a quota cop, and I don't think anyone can or should force writers to write more diverse characters. Writers are free to write what they want and viewers are free to watch what they want, that's just one thing that makes this country great! To address this point, let's look back to Holmes' original post:

"This is not an angry letter. It is especially not an angry letter about Up, which I adored. I could have sat in the theater and watched it two more times in a row. I cried, but I also laughed so hard in places that it wore me out. So I'm not complaining; I'm asking. I'm asking because I think so highly of you. Please make a movie about a girl who is not a princess."

This isn't a militant demand for social equality. There's no moral indignation and condemnation. No one is chaining themselves to the movie projector or hosting some hedonistic hippie love-in. These are the words of a fan asking for something more. As anyone involved in business knows, when the consumer speaks, it's important to listen.

So what?
By far, the most frequent response was of the "So what?" variety. Who cares that all the leading characters are men? What's the big deal? Women have Lifetime and blacks have BET and rap music, why would they possibly want more? Why does it matter? It matters.

First, there is the notion of identification. How many guys out there grew up wanting to be like Han Solo? Or learned how to woo women from watching James Bond? Personally, I always wanted to be an archeologist...until I learned that being a professor of archeology was not nearly as cool as being Indiana Jones. So now I'm gunning for professor of psychology, which is even way less cool. As Megan (check out her cool blog of open-letters) wrote: "It sends a message when these cool stories feature a male character as the lead. The supporting female roles are usually great- funny, quirky...But it doesn't really matter how strong the female characters are when they are consistently cast as support and never given the lead. This sends a message to little girls. There's nothing wrong with those roles in theory, it's important to support and love, but the female characters need a chance to be supported for a change...Give the girls a chance to shine."

Also, variety is the spice of life!...and that says a lot coming from a guy who is notorious in a few Cambridge eating establishments for ordering the exact same meal at the exact same day and time each week. How many people have complaints about stale Hollywood studio movie formulas? If you want the standard pat evolutionary psych argument...diversity is an evolutionary entertainment advantage, it's bred into our genes!

Let's try a little thought experiment. Teenagers with mostly disposable incomes are a lion's share of entertainment consumers and a leading target demographic. Let's say that studios decided to capitalize on this market by hiring high school students to write, produce, star in and direct over 90% of the studio's flagship films. If you think you're sick of seeing Shia LaBeouf now, just wait until those freshmen students get control. It'll be all Twilight and Harry Potter. High School Musical 5 will hold the top spot on the box office charts for eight weeks in a row. The Jonas Brothers meet Hanna Montana biopic will take home the Academy Award for Best Picture. Sure, the Titanic sank...but I smell prequel! I'll just go see something else, you say? That'll be pretty tough when Step Up 4 More Dancing On The Streets, The Sisterhood of the Traveling Pants part 6 - Sisters in Slacks, and Bring It On All Over Again take up the other screens in the multiplex. So silence your cell phone, grab your popcorn, sip your soda and settle in...The Princess Blogs is about to begin.

----------------------

Does a tween theater totalitarian takeover sound terrifying to you? Comment below! Email correspondence to jareddefifept@gmail.com

Hey Pixar, What’s Up? Try Finding an Incredible Story about a Girl’s Life

Jared DeFife, Ph.D. — Sat, 13 Jun 2009 19:51:18 +0000

...and one who isn't a princess, please. "Dear Pixar, From All The Girls With Band-Aids On Their Knees" is a recent post from Linda Holmes to her NPR.org blog, Monkey See. The post is an open letter to Pixar in praise of their films, but in it, Holmes also identifies a notable omission from their cinematic corpus: a lack of a single leading female character.

"Of the ten movies you've released so far, ten of them have central characters who are boys or men, or who are anthropomorphized animals or robots or bugs who are voiced by and imagined as boys or men. These movies feature women and girls to varying degrees -- The Incredibles, in particular -- but the story is never ‘a girl and the things that happen to her,' the way it's ‘a boy and what happens to him'."

Decrying biases and stereotypes is often too-easy [look hard enough for some data to confirm your beliefs and you can find it most anywhere, a phenomenon known as confirmation bias], but Holmes's argument hardly seems like "P.C. B.S.". Animated films have traditionally allotted roles for women as princesses, as damsels in distress, evil witches/stepmothers, dead mothers, or princesses in distress. Par exemplar, Disney is hailing their return to a proud tradition of 2D animation with The Princess and the Frog (if you think Disney's gender roles are bad, you should check out their ethnic stereotypes).

Pixar hardly seems a particularly malevolent offender as their films do have a number of engaging female characters, but ones who mostly, as Holmes notes, appear as "a side dish". This isn't the first time such an argument has been leveled at Pixar (though the criticism could be made of American movies in general). A year ago, Caitlin GD Hopkins wrote that: "What I am taking issue with is the ad-nauseam repetition of female characters as helpers, love interests, and moral compasses to the male characters whose problems, feelings, and desires drive the narratives." Just as big a problem perhaps, is what happens to storylines and characters of girls grown up.

One argument typically made when these discussions come up is that female-driven storylines outside of the romance or drama genres are harder to market and won't sell well. While that might hold some water, I don't entirely buy it. Coraline has done just fine, as has her literary ancestor, Alice in Wonderland. Persepolis, anyone? To paraphrase a man who chronically suffered from Pixar's plight of not writing female leading characters (despite most of his writing being completed under a female monarch), Would not that which we call a Potter by any other gender (a Haley Potter, perhaps) be still as sweet? For action, there's Aliens and Alias and Kill Bill and Buffy. And then there's the case of ‘a girl and the things that happen to her' which involves a girl, her dog, the tornado that sweeps them off to a strange land, and some friends she meets and leads along the way. After that, a whole lot of people were very interested and paid a lot of good money to see what went on in that strange land before Dorothy dropped in.

A good story well-told can always be sold. The dearth of quality female-led films in multiplexes is surely more a problem of supply than it is of demand. Perhaps the problem starts with the fact that about 90% of mainstream American movies are directed by men, not to mention how many men are doing the writing and producing. And if any of them think like As Good As It Get's Melvin Udall, then we're all in trouble.

What's your take? Why's a good woman so hard to find? Comment below! Email correspondence to jareddefifept@gmail.com

Should Insurances Pay for Therapy?

Jared DeFife, Ph.D. — Thu, 11 Jun 2009 22:19:21 +0000

What are your thoughts on and responses to the question:

Should health insurance providers pay for psychotherapy, and why?

This is one of the most widely discussed and hotly contested debates in the field of mental health. So, I thought we'd try a little blogging experiment here and collect as many of your comments and opinions as possible on this issue. If we can get get together enough responses, I'll follow-up with a post synthesizing your answers and add a few thoughts and opinions of my own.

Some related issues that could come up:

For what conditions? For how long? For what treatment methods? Provided by whom? Is mental illness a medical concern? Should therapy be covered even if there is no diagnosable or impairing disorder? In what ways is therapy a luxury item for the worried well, a community service, or a medical treatment? Are the current costs of therapy fair...or how much should therapy cost? Who becomes the guide for treatment planning? What therapy information should be given to your insurance companies?

Let your voice be heard by posting a comment below!!! And spread the discussion...tweet it, facebook post it, blog it, ask at the water-cooler, etc!

Email correspondence to: jareddefifept@gmail.com

Eating Disorders On The Rise, Part II: Weighing The Evidence For Psychotherapy

Jared DeFife, Ph.D. — Sun, 07 Jun 2009 00:04:09 +0000

As a social culture, we can't seem to find a healthy balance when it comes to weight. On one hand, we're an increasingly obese nation with all of the added weight of health complications. On the other hand, we're either heralding or demonizing celebrities for drastic shifts in body weight.

We're as perplexed as the characters in Kafka's short story A Hunger Artist:

"I always wanted you to admire my fasting," said the hunger artist.
"But we do admire it," said the supervisor obligingly.
"But you shouldn't admire it," said the hunger artist.
"Well then, we don't admire it," said the supervisor...

Given our perpetual fascination with and raging envy of thinness, the prevalence of eating disorders should come as no surprise. Communities have emerged in celebration of Pro-Ana or Pro-Mia lifestyles, promoting "thinsporation" and advice. But eating disorders are not fashionable and glamorous. They are not lifestyle choices or spiritual experiences. They are devastating illnesses with severe consequences.

In a previous post, we examined methods that researchers use to evaluate whether or not psychotherapy "works". By nature, psychotherapy is not highly conducive to rigorously controlled experimental methods. Experimental studies of psychotherapy, known as RCTs, tend to be conducted with very brief, tightly manualized interventions with patients who demonstrate a very discrete symptomatic pattern. Then again, is a tightly controlled experiment really the most useful method for studying the complex, pervasive, and persistent phenomena seen in psychopathology and treated in psychotherapy? More observational studies of psychotherapy as practiced in real-world treatment settings over time have greater difficulties identifying the specific causal factors of change.

First, one obstacle for investigating treatment of eating disorders, as one of my perceptive readers commented on to part I, is diagnosis. The exceptionally paltry Eating Disorders section of the DSM-IV-TR lists three diagnostic categories: Anorexia Nervosa (which has a hallmark of a body weight less than 85% of expected for an individual's height/age); Bulimia Nervosa (identified by a cycle of binging and purging behavior); and Eating Disorder Not Otherwise Specified/NOS (in which disordered eating patterns cause significant physical/psychological distress, but with symptoms that do not match any existing diagnostic category).

Not surprisingly, an excessive number of cases fall into the NOS diagnostic category. The recent report from the Agency for Healthcare Research and Quality identified that hospitalizations for atypical forms of eating disorder are most sharply on the rise. Without a focused definition of a disorder, a controlled experimental study of treatment is more difficult to conduct.

Let's look at some evidence from psychotherapy Randomized Control Trials, which are allegedly the "gold standard"* for identifying "Evidenced Based Treatment". What do they tell us about psychotherapy for eating disorders?

Unfortunately, there appears to be little to no repeated RCT evidence of a consistently and lasting beneficial psychotherapy for the treatment of Anorexia Nervosa. The American Psychiatric Association identifies a few sparse trials with very small samples. One study found 20 sessions of nonspecific clinical management to be as effective as either Cognitive-Behavioral Therapy (CBT) or Interpersonal Therapy (IPT). Another study found one-year of CBT to be more effective than one-year of nutritional counseling. In a third trial, patients in psychoanalytic psychotherapy, family therapy, and cognitive-analytic-therapy (an adaptation of psychodynamic psychotherapy) were found to achieve greater improvement over a group with low-contact treatment-as-usual. Yet, in each of these trials, improvements were minimal and gains were only observed in a small percentage of the patient sample. In terms of what patients found helpful about treatment: "support, understanding, and empathic relationships were rated as critically important, psychological approaches were rated as the most helpful, and medical interventions focused exclusively on weight were viewed as not helpful".

It seems that Anorexia may well be one of, if not the single, most difficult forms of mental illness to treat. It's a particularly entrenched disorder in its own right, and when one adds the serious medical/physical complications involved, the problem can quickly become very life-threatening. As an aggregate whole the field has not yet demonstrated robust efficacy for psychotherapy of anorexia, but this does NOT mean that certain individuals with anorexia can't be helped, and perhaps provided life-saving help, from psychotherapy.

Evidence from RCTs for the treatment of bulimia is better, but still very limited. Meta-analyses (research which compiles results from multiple studies) demonstrate that the brief interventions provided in RCT studies do result in statistically significant improvements of eating disorder symptoms and improved levels of functioning.

The bad news is this: "two thirds of BN [Bulimia Nervosa] patients who receive individual psychotherapy with CBT-the most efficacious treatment studied to date-either drop out or fail to recover by termination, and patients who do not recover tend to retain symptom levels surpassing the DSM-IV criteria for the disorder" (Thompson-Brenner and Westen, 2005, p. 573).

I'm reminded of a saying I've heard many many times having grown up with the Cleveland Browns as my local football team: "sure, the team sucks now, but at least we're better than last season". That mentality just isn't good enough. Does that mean that there's little hope for psychotherapy to help? Not necessarily so. In the next post, we'll look at what happens when we take our investigation of psychotherapy outside the research lab and into the real-world.

_____________________________

Weigh-in with your thoughts, concerns, or questions by commenting below.

*The term "gold standard" actually applies to an economic theory that no country currently practices and fell apart decades ago in real-world implementation. Furthermore, the longer a country adhered to a gold standard, generally the greater was its economic severity and time to recover from the Great Depression. As applied to the canonization of RCT methodology for guiding clinical practice, this may be an apt metaphor.

Thompson-Brenner, H., & Westen, D. (2005). A naturalistic study of psychotherapy for bulimia nervosa, Part 1: Comorbidity and therapeutic outcome. Journal of Nervous and Mental Disease. 193(9):573-84.

Email correspondence to jareddefifept@gmail.com

Eating Disorders On The Rise, Part I: How Do We Find Out If Psychotherapy Helps?

Jared DeFife, Ph.D. — Sat, 04 Apr 2009 19:58:30 +0000

The Agency for Health Care Research and Quality has released a report identifying a sharp rise in eating disorder hospitalizations. Can psychotherapy help with these debilitating disorders?

The eating disorders are particularly scary forms of mental health distress. There are a range of clinical presentations of eating disorders, some of which include: poor body image, unhealthy approaches to weight loss including restrictive diets and excessive exercise, binge eating, purging through use of laxatives or vomiting, or consuming non-edible objects (pica). Even in ‘milder forms' of these disorders, the physical cardiac, gastrointestinal, esophageal, and nutritional consequences can be devastating. Medically complicated hospitalizations are frequently necessary (often in light of a strong resistance to receiving necessary medical treatment) and accidental death rates are high. Many clinicians are extremely hesitant to admit to their caseloads patients with eating disorders due to the physical risks involved, the time-intensive collaboration with medical treaters, and the persistent nature of these disturbances.

Can psychotherapy help patients with eating disorders?

First, we need to look at how researchers and clinicians try to find out if psychotherapy works or not. In a follow-up post, we'll explore some published treatment results for eating disorder treatment.

There are three common research approaches to examining psychotherapy's effectiveness (something I've briefly discussed in a previous post on treating depression):

Randomized Control Trial (RCT): In a randomized control trial, participants are randomly assigned to a treatment condition. Some patients are given only psychotherapy, others may receive only psychiatric medication, some may be given placebo treatment, and some may not receive any treatment at all and be placed on an extended wait-list. The point of a psychotherapy RCT is to answer two questions: 1. Does psychotherapy work? and 2. Does psychotherapy work better than no-treatment and/or other treatment options? In order to make a causal statement (i.e. the patient got better BECAUSE of the therapy, and not for some unrelated reason), the experiment needs to be as controlled as possible...a sort of therapeutic "clean room". That means that patients are carefully selected to have pure forms of the disorder being examined and that treatments are rigidly manualized and treatment protocols are faithfully delivered. Furthermore, the participants are supposed to be "blind" to the treatment being received. That means the patient isn't supposed to know if they are receiving a placebo or an active treatment, and experimenters interacting with the participants aren't supposed to know what treatment is being delivered either.

You can already see one inherent flaw in this model: how does a patient not know they are receiving psychotherapy, and how can clinician not know that they are practicing a particular psychotherapy? Another dilemma in this model is how to deal with the factor of time. It is said that time heals all wounds, but is that true? It is very hard to maintain a clean psychotherapy study for any long period of time. How many people have a single, well-defined psychological disorder with no-other co-existing problems like depression, anxiety, physical illness or substance use? Furthermore, it's difficult to stick to a manual for a long time when you are interacting with other human beings who have unique needs and desires. On top of that, one has to assign a group of people to a condition where they receive no treatment.

Imagine you have an incredibly distressing and physically damaging condition. Now imagine your doctor telling you have to agree to wait a long period of time before they'll give you treatment. What ends up happening is that the treatments delivered in RCT are often very short (8-16 sessions, usually) and mostly behavioral, skills training, or cognitive-behavioral in nature. While it is clear that a short period of treatment can yield significant symptomatic improvements, patients completing an RCT treatment may still have significant pathology and a high proportion of people don't get better at all.

RCTs have been declared the "gold standard" for defining "evidence-based treatment". As you can see, there are a whole host of problems in allowing this research methodology to dictate clinical practice. In that sense, the term "gold-standard" might be well used here given that the term relates to an economic policy which has no current real-world implementation and fell apart as a feasible practice in the U.S. way back in the 1930s.

Effectiveness Studies: Do parachutes work to save the lives of human beings jumping out of an airplane? How do you know? To my knowledge, there's never been a randomized control trial where jumpers are randomly assigned to a parachute or no-parachute condition. What about wearing a seat-belt to prevent death in a car accident? Same thing...no way to do an RCT (okay it's possible, I guess, but I imagine it would come with a significant amount of jail time). Effectiveness studies measure treatment outcomes in people receiving psychotherapy in actual community or private treatment settings. Most people know pretty definitively that mental illness doesn't just go away with time (in fact, many times it gets worse without intervention). In an effectiveness study, we look at how patients come into treatment and measure how they change over time. If their symptoms, behaviors, and well-being improve, we infer that their treatments worked. Of course, in an effectiveness study, we can't draw a definitive conclusion that our treatment was the reason for that change...maybe the illness just got better on its own, maybe the patient got a great new job and felt better, or maybe they got a new pet that makes them happy. But if we have a large enough group of people who show a consistent pattern of getting better, we can make some pretty common sense inferences about the usefulness of treatment.

Meta-analyses: A meta-analysis involves digging up as many studies as one can find in a specific field (say, all studies done treating eating disorders). Any one research study could happen to give some exaggerated or inconsistent finding. To get a better picture of the true effect, a meta-analysis compiles more information from as many studies as possible. Because I love sports metaphors for psychology: Let's say the Boston Red Sox play a baseball game against their contemptible competitors, the New York Yankees. The Red Sox deliver a crushing defeat: 12-0. Are the Red Sox a better baseball team? (Yes, of course they are...but let's support that with more evidence) To answer that question more accurately, we would have to look at all the many games the teams play against each other through the season. If Boston consistently wins more games (of course they do), then we have more evidence to say that they are the better baseball team.

Now that we've seen some ways researchers evaluate psychotherapy, in a follow-up post we'll look to answer the question: Can psychotherapy help patients with eating disorders?

Improving Access to Mental Health Care: Is There a Shrink in the House?

Jared DeFife, Ph.D. — Sun, 22 Feb 2009 19:46:45 +0000

Ever tried to get a mental health care appointment as a new patient? How long can you wait before seeing someone? How many phone calls before throwing up your hands in frustration? Problems with the system include a complicated referral system, the need to obtain written referral forms from a primary care physician, trouble finding clinicians who will take one's insurance, struggles to find clinicians who are accepting new patients, inconvenient treatment locations, and long waiting times. The process can be demoralizing, leading to increased desperation, disrupted continuity of care or even the failure to obtain proper care at all.

One approach to the problem has called for greater integration of mental health care professionals in primary care/general practitioner treatment settings. In a new study published in the journal Psychiatric Services, Dutch researchers examined the effects of having mental health care professionals (psychologists and psychiatric nurses) working on site at primary care practices. Known as a collaborative care model, mental health clinicians worked in tandem with primary care physicians and were available to meet patients for clinical assessment, brief psychotherapeutic intervention (maximum of four sessions), and, if needed, referral to more specialized psychiatric services.

The collaborative care treatment settings were compared with treatment-as-usual clinical practices in which patients identified by primary care doctors as needing mental health services were referred to external mental health practitioners/agencies. 165 patients participated and were evaluated after twelve months.

Both collaborative care and treatment-as-usual settings were effective and not significantly different in terms of reducing patients' psychopathology, increasing their quality of life, and obtaining patient satisfaction.

However, in the collaborative care model:
-First meeting with a mental health care professional occurred much more quickly (average of just under 3 weeks versus over 6 weeks in treatment-as-usual settings).

-Patients showed similar improvements, but needed fewer sessions to get there...

-...leading to significantly lower treatment costs (an average yearly savings of $725 per patient).

-Fewer patients remained in treatment after 12 months, presumably because they no longer felt the need for treatment services, though this is unclear.

-General practitioners were significantly more satisfied with their time saved, workload reduction, and patient improvement.

Having mental health providers on-site and working collaboratively with primary care physicians seems to provide better access to care, make good fiscal sense, and give relief to an overtaxed health care system. When choosing a primary care provider, it would be wise to find out if there's a (mental health) doctor in the house.

_________________________________________
What are your thoughts about access to mental health services? Have ideas about improving the process? Comment below! Email correspondence to jareddefifept@gmail.com.

Being single ain't all it's cracked up to be

Jared DeFife, Ph.D. — Fri, 20 Feb 2009 18:22:40 +0000

Being single ain't all it's cracked up to be...

A recent study was published which compared attachment patterns of long-term singles and coupled adults.
A quote from the abstract: "Single participants were as likely as coupled ones to exhibit attachment security and rely on attachment figures, although compared to coupled participants they reported higher levels of loneliness, depression, anxiety, sexual dissatisfaction, and troubled childhood relationships with parents."

Whoa, whoa, whoa. Higher levels of loneliness, depression, anxiety, sexual dissatisfaction?? It's enough to make a guy want to sign up for match.com right away. In two recent postings, Bella DePaulo praises the study for finding that singles and couples did not differ significantly in attachment security, but then tries to "debunk" the article as an example of insidious "singlism" at work. Unfortunately, looking at study findings is not like dating; you shouldn't just make eyes for the ones you like and dismiss the ones you find less personally appealing.

Let me say that I often find DePaulo's posts refreshing and insightful. Her efforts to identify "singlism" in the world are admirable. They encourage self-reflection for all, and offer empowerment to the masses of single people out there. That's all the more reason for me to be disappointed at the representation of the Schachner, Shaver, and Gillath study.

Would not a title by any other name smell as sweet?
First, let me start with the title of DePaulo's recent posting: "No attachment issues among single people". Ok, we're writing a blog for the popular press. As one of my readers once noted, this ain't JAMA or the New England Journal of Medicine. When we talk about research studies here, we try our best to represent the findings accurately while still keeping people awake (if science was super-thrilling and sexy, the Journal of Consulting and Clinical Psychology might have a larger readership than People Magazine). In this format, we often write attention-grabbers to get people interested, have little space to discuss complexities, neglect nuance and make bolder claims than we might in our academic writing. I'm guilty of it (Say it ain't so, Joe! It's so.), but let's just keep that among us, k? "No attachment issues among single people" makes for a much better title than "one study shows that on a self-report measure of attachment, no significant differences in ratings of attachment security were found for a small sample of couples and single people". However, the study suggests that there are no significant DIFFERENCES in attachment issues, NOT that single people or coupled people have no attachment issues. And no attachment issues among single people?? Really? I know single people with attachment issues, so that kinda nixes the statement right there. Maybe you have attachment issues, too...I'll even go all Cosmo-style and link to a little attachment quiz.

There's more to the story...
Please consider that the study does not say "single people have no attachment issues" by any stretch (nor am I saying that all single people have attachment issues!!!). The study says a lot of complex things. From its many findings, it demonstrated that among the small group of single and coupled individuals participating:

THE GOOD NEWS...
-the single and coupled individuals overall reported similar levels of attachment security

-the single and coupled individuals both had similar attachment relationships with others

-they just had different people in their lives meeting their attachment needs

THE NOT-SO-GOOD NEWS...

-the single men had greater attachment anxiety than the coupled men

-the single individuals rated higher levels of depression and anxiety symptoms

-singles reported more casual sex partners and masturbated more, but reported lower levels of sexual satisfaction

-singles reported more problematic childhood relationships with their parents

-when interviewed about relationships, coupled individuals more often used the word "supporting", while single individuals more often used the words "lonely", "rejected", "alone", and "isolated"

The not-so-final word
DePaulo is right to point out ways in which study results get WAY overgeneralized. This happens particularly in media formats in order to make stories more lively, interesting, and relevant to peoples' lives. She is also wise to point out that there is a lot of bias and discrimination out there against singles. The fact of the matter is that people come in all stripes and sorts. There are plenty of couples who are miserable, plenty of blissful singles...and vice versa. In clinical practice, I've seen plenty of people repeat dysfunctional attachment patterns in their current dating practices, contributing to significant interpersonal distress. Also, I've seen plenty of people repeat dysfunctional attachment patterns in their romantic relationships and marriages, contributing to significant interpersonal distress. While the study suggests that singles have similar attachments as their coupled counterparts, it also suggests that, for many, being single has its drawbacks.

----------------------------------------------------------------------------
Have any thoughts about those who are....coupled and cranky? Single and stellar? Alone and lonely? Paired and pleased? Share your responses by commenting below or by email to jareddefifept@gmail.com

Photo courtesy of Ted Szulkalski at http://www.digital-photo.com.au/.

Those ideas go back further than you think... neglecting the heritage of psychoanalytic theories

Jared DeFife, Ph.D. — Sat, 14 Feb 2009 15:14:31 +0000

Stepping aside from the style of my usual postings, this post is a sort of slap-dash academic reaction to a statement in "Love Sick on Valentine's Day? You Already Have the Cure".

It's a great post about how we come equipped with implicit processes for managing affect. I wanted to supplement it by noting some neglected historical antecedents Psychoanalytic theories are often treated like skeletons in the closet of modern psychology...ignored or repudiated. Of course, some other people treat them like Biblical verse, but that is less frequently the case. There are aspects from those writings that may be flawed, built upon, sketchy or dismissed, but when an idea is handed down it's important to respect one's intellectual heritage.

An example of this benign neglect: "One reason, proposed originally by social psychologists Daniel Gilbert and Timothy Wilson, is that people are unaware of psychological defenses they have that reduce negative emotions."

The idea that outside of awareness there exist cognitive processes for the reduction of difficult affect was hardly proposed originally by Gilbert and Wilson. It's been kicked around in psychology for over a century.

For the easy run-down, see wikipedia's entry on "defence mechanism" http://en.wikipedia.org/wiki/Ego_defenses

Waaaay back in the 19th century, Freud talks about unconscious processes that separate unbearable affect from an idea. See Freud, S. (1894) The neuro-psychoses of defence.
Freud, S. (1896) Further remarks on the neuro-psychoses of defence.

Anna Freud described numerous forms of these defense mechanisms in The Ego and Mechanisms of Defense in 1936. Both Anna and Sigmund wrote about defenses occurring in reaction to unbearable affect arising from instinctual urges.

Even before Anna Freud, Alfred Adler wrote about "safeguarding tendencies"! Of Adler's writing, Heinz Ansbacher, in The Individual Psychology of Alfred Adler, said that "Freud's defenses provide protection of the Ego against instinctual demands. Whereas Adler's safeguards protect the self esteem from threats by outside demands and problems of life."

Over the years, social psychologists have done a great job of using experimental methodology to identify self-esteem enhancing behaviors.
Baumeister RF, Dale K, Sommer KL (1998) Freudian defense mechanisms and empirical findings in modern social psychology: Reaction formation, projection, displacement, undoing, isolation, sublimation and denial. J Pers. 66:1081-1124.

Phoebe Cramer has written about how the concept of "defense mechanisms" occurs throughout different branches of psychological discipline. Cramer P (2000) Defense mechanisms in psychology today: Further processes for adaptation. Am Psychol. 55:637– 646

One thing that consistently occurs throughout the writing on defenses, is that some defense use is adaptive (managing affect and building self-esteem) versus some use that is maladaptive (creating interpersonal discord, isolation, breaks in reality testing).

Our thinking about psychological defenses (or adaptive coping styles) has come a long way over the past century. Whatever one thinks about early psychoanalytic theories, and even flawed as they are, they often miss out on the the historical/intellectual credit and citation they deserve when discussing ideas that were derived from them.