One of the reasons I became interested in family systems theory, tribalism, family myths, social psychology, and other manifestations of collectivism was because I noticed a big problem with the predominant types of psychotherapy practiced with individuals (psychodynamic, cognitive-behavioral emotion-focused therapies). 

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

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

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

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

I thought of this issue after reading an article entitled “Ecological Momentary Assessment in Borderline Personality Disorder: A Review of Recent Findings and Methodological Challenges” (Santangelo, Bohus, & Ebner-Priemer, Journal of Personality Disorders 28 (4), pp. 555-576), 2014. 

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

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

As the authors reviewed the results of prior studies using this methodology in subjects with borderline personality disorder (BPD), a hidden assumption just jumped out at me. The authors were just plain ignoring environmental issues while making the fundamental attribution error in drawing conclusions. 

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

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

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

Why are the subjects not also asked in their diaries to describe the stressors to which they are reacting? Is it all in their heads? Or is it because therapists, like a lot of people these days, don’t want to look at what is actually going on in families?

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

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

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

Without any descriptions of the nature of the stressors, we can not really come to valid conclusions. Of course, it should go without saying that people who are under severe stress are going to be far more likely to respond with more severe emotional reactions than people who are under far less significant stress. 

You are reading

A Matter of Personality

Where Psychotherapy Goes Wrong

Today's therapists have a myopic focus on what goes on inside a patient's head.

Research Into Borderline Disorder: A Mindless Assumption

Researchers assume that one's social environment counts for nothing.

How To Fail at Family Problem-Solving

Here are some common mistakes made in discussing mutual interactions.