The lure of rapture

Fundamentalist Christian minister Harold Camping of Oakland, California, has widely publicized that today is the day of the Rapture, when according to some interpretations of the New Testament true believers ascend to heaven to escape impending misery and turmoil on Earth.  I am writing in the afternoon, and can't guarantee just yet that Camping is mistaken.  But let's assume he is: He was wrong before, and he is just the latest in a long string of mistaken end-times prophets.  I promise to post a prompt, heartfelt apologetic retraction if he turns out to be right — and if the internet and I survive the initial cataclysm. I have a few reflections on end-time prophesies, starting with the admission that I've always found them oddly alluring. As a child, I knew I would be alive in the year 2000.  In my young mind this futuristic date glittered with flying cars, modular glass homes, one-piece unisex jumpsuits that somehow didn't look absurd, and one or more Moon colonies.  But in addition, I had repeatedly heard predictions that Christ's Second Coming would coincide with the new millennium.  Although there is plenty of theological controversy on this point even within Christianity, and even though I was not raised to believe anything of the sort, it always struck me as exciting that  such a grand moment might actually take place in my lifetime.

With the year 2000 come and gone, most end-time attention has since moved to 2012, when, among other things, the Mayan calendar supposedly runs out of dates.  Even so, I wonder whether Mr. Camping, who is 89 years old, is consciously or unconsciously motivated by the possibility that this greatest of historical events might occur in his remaining natural lifetime.  Perhaps it is human nature both to hope and to believe that we live in a unique time.  A touch of narcissism perhaps?

Psychologists and others have wondered, and occasionally studied, how believers deal with mistaken prophesy.  What will Camping and his followers do or say tomorrow?  Leon Festinger's classic 1956 study "When Prophesy Fails" suggests that rather than recanting his beliefs, Camping is apt to rationalize his failed prophesy.  For example, he may realize his calculations were off, or declare a divine 11th hour reprieve for the world.  Of course, some followers, perhaps the majority, are apt to feel disillusioned and humiliated.  The "Great Disappointment" of 1844 offers the historical precedent of a similar failed prophesy.

There is a non-religious definition of rapture: "n. the state of being carried away with joy, love, etc.; ecstasy."  In a larger sense, we all seek to connect with something bigger than ourselves.  For many, it is religion and its connection with God.  Others find connection and larger purpose in humanitarian or political work.  Playing music or team sports with others can satisfy this need to some extent, as can being part of the crowd at a concert or other event.  Even mobs and riots satisfy this need, albeit in destructive ways.  The lure to belong, to share experiences with others, to have a larger purpose, to be "in a groove" seems innate.  I once saw a greeting card that read, "People who never get carried away... should be."

It is really no surprise that doomsayers capture headlines and our attention.  Whether we expect to rise to heaven today with God's Chosen, or join others in ridiculing the gullible — or blog to readers on the internet — we all can be part of a grand spectacle.  It makes this sunny Saturday more special than it would otherwise be, and ourselves a bit more connected to feelings, purposes, and forces greater than ourselves.

Conflicts of interest in medical education: Disclosure may not help

Yesterday's New York Times had an interesting op-ed, "Stumbling into Bad Behavior," about corruption and unethical conduct in corporate and financial settings.  The authors, Max H. Bazerman and Ann E. Tenbrunsel, are academics who wrote a book about ethical blind spots.  They note that regulators, prosecutors, and journalists tend to focus on corruption caused by willful actions or ignorance, but this overlooks unintentional lapses:  "Our legal system often focuses on whether unethical behavior represents 'willful misconduct' or 'gross negligence.' Typically people are only held accountable if their unethical decisions appear to have been intentional — and of course, if they consciously make such decisions, they should be. But unintentional influences on unethical behavior can have equally damaging outcomes." This caught my attention as it relates to conflicts of interest in medicine.  For example, I have long expressed ethical concerns regarding the willful participation of physicians in pharmaceutical promotion.  It is a clear conflict of interest to purport to be an unbiased advisor to patients, while at the same time choosing to attend (or deliver) overtly slanted marketing presentations.  However, defenders of such participation say they deserve more credit: They cannot be corrupted, and would never willingly deliver biased medical advice no matter how drug or device manufacturers reward them.

These positions are reconcilable given that bias is often unconscious and unwilled.  Bazerman and Tenbrunsel note:  "[M]uch unethical conduct that goes on, whether in social life or work life, happens because people are unconsciously fooling themselves. They overlook transgressions ... because it is in their interest to do so."

Psychiatry, of course, has a lot to say about how people fool themselves.  We discount our own lapses to maintain our self-esteem.  We may employ psychological denial to make our troubling inconsistencies disappear, or utilize projection to attribute our faults to others.  We may reframe liabilities to look like assets — and we may do all of these outside of our own awareness.  Thus, it is entirely consistent sincerely to consider oneself principled, ethical, and unbiased, and yet to be undermined by one's own unconscious mind.

To me, the most striking paragraph of the op-ed questioned the value of disclosing conflicts of interest, an issue I've raised in the past.  As chair of Continuing Medical Education (CME) at my medical center, I am forever badgering CME speakers to provide a "disclosure slide" at the start of their talks.  (CME is required to maintain medical licensure and stay up to date, so all physicians must attend many hours of CME annually.)  This disclosure of financial ties to industry, and other potential sources of bias, is required by state and national CME oversight bodies; the medical center risks its CME accreditation if this rule is not followed.  Yet the value of disclosure has always felt tenuous to me.  Maybe it's better than nothing, I thought, but simply disclosing potential conflicts of interest hardly guarantees that the talk will not be biased anyway, nor that the physician audience will know how to evaluate the imparted information given the disclosure.

The New York Times op-ed cites a 2005 study that clarifies this matter of disclosure in a very useful if sobering way.  "The Dirt on Coming Clean: Perverse Effects of Disclosing Conflicts of Interest" by Daylian M. Cain, George Loewenstein, and Don A. Moore discusses what disclosure intends to remedy, versus what it may actually do given unconscious as well as conscious factors.  The authors point out that people generally do not discount advice from biased advisors as much as they should, even when advisors’ conflicts of interest are disclosed.  Moreover, disclosure can actually increase the bias in the delivered information because it leads the disclosers to feel morally licensed and strategically encouraged to exaggerate their advice even further.  The paper reports an empirical study conducted with Carnegie Mellon University undergraduates that supports these concerns.  The authors conclude:

[D]isclosure cannot be assumed to protect recipients of advice from the dangers posed by conflicts of interest. Disclosure can fail because it (1) gives advisors strategic reason and moral license to further exaggerate their advice and (2) it may not lead to sufficient discounting to counteract this effect. The evidence presented here casts doubt on the effectiveness of disclosure as a solution to the problems created by conflicts of interest. When possible, the more lasting solution to these problems is to eliminate the conflicts of interest.

I couldn't have said it better myself.  The op-ed likewise concludes that, "Good people unknowingly contribute to unethical actions, so reforms need to address the often hidden influences on our behavior."  When it comes to unbiased medical education, neither good intentions nor disclosure of potential bias is sufficient.  The solution is to admit we are fallible humans, and to avoid sources of bias, conscious and unconscious.  Psychiatry could help — if it weren't so complicit itself.

Diagnostic alphabet soup

Earlier this year a reader asked me: "I would be very interested to hear your thoughts on patients becoming too focused on diagnoses. [...] While I was in an RTC as a teenager, and recently in the hospital as an adult, I have found that people almost treat their diagnoses as a competition. I was calling it the alphabet olympics. I also have a friend who will rattle off a bunch of abbreviations for his diagnoses. There is always something new popping up too. Sometimes I wonder if over diagnosing is a mistake some psychiatrists make."

I've seen this too.  Here's my take on the alphabet soup of diagnosis, and whether it's good for patients to focus on it.  First, a little history...

Prior to 1980, before the revolutionary 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), psychiatry tended to lump disorders into a few broad categories.  Schizophrenia covered a wide range of presentations, from relatively minor symptoms to devastatingly severe ones.  Depression could be brief, prolonged, triggered by obvious stressors or losses, or appear out of nowhere.  Neurosis referred to any presumed unconscious conflicts that interfered with life.

DSM-III changed all that.  (An excellent historical review article, in pdf format, is available here.)  This was the first effort by the American Psychiatric Association (APA) to publish an atheoretical, phenomenological psychiatric nosology.  What do these $10 words mean?  The idea was to create diagnoses that could be used regardless of one's school of thought or theory.  For example, some psychiatrists thought depression was biological, others considered it psychological.  Either way, if a patient had a low mood for two weeks, along with poor sleep, appetite, concentration, and libido, he or she had Major Depressive Disorder according to DSM-III.  It didn't matter why.

This scheme encouraged multiple diagnoses.  A given patient could fulfill criteria for Major Depressive Disorder, an Anxiety Disorder, a Personality Disorder, and other disorders, all at the same time.  This reflects a drawback of atheoretical diagnosis.  An underlying theory, such as Freudian psychoanalytic theory, or a systematic biological or learning theory, can pull together apparently disparate symptoms into a coherent diagnostic formulation.  Without such a theory to guide diagnosis, each set of symptoms stands on its own.  While some DSM diagnoses had exclusion criteria — they could not be listed in the presence of other diagnoses — this still left plenty of opportunity to list multiple disorders in the same person.

Each edition of the DSM grows in size.  One reason is that scientists can't stand to leave a good category alone — if it can be turned into two good categories.  Thus, anorexia and bulimia, which used to be one disorder, are now divided.  Depression is divided into major depression, dysthymia, seasonal affective disorder, adjustment disorder with depressed mood, and so forth.  Bipolar disorder comes in Type I and Type II, as well as lesser versions.  I am not against making these distinctions when there is good reason to do so, and there often is.  But one consequence is diagnostic alphabet soup: a growing set of arcane labels usually shortened to three- or four-letter abbreviations.  And the nature of atheoretical diagnosis means that any given patient may qualify for several.

Many psychiatrists feel they "understand" a patient better if they can establish one or more DSM diagnoses — although, being atheoretical,  such diagnoses don't actually explain anything.  They do, however, point reassuringly to recommended treatments, usually pharmaceutical.  Moreover, medications are FDA-approved for each of these indications separately.  This has marketing advantages for drug manufacturers.  Shyness doesn't sound like a psychiatric problem to be treated with medication, but "Social Anxiety Disorder," essentially a synonym for shyness, does.  Dividing anxiety into Generalized Anxiety Disorder, Social Anxiety Disorder, and many other types created markets for various medications.  In a parallel fashion, health insurers demanded more specific diagnoses in order to pay for psychiatric treatments.  There is money, and therefore politics, behind dividing human misery in these particular ways.

Perhaps the most interesting part of my reader's question is why some patients are attracted to these labels.  Her experience with teens and young adults may, in part, reflect embracing these labels in an ironic or mocking way:  "Now I have MDD, OCD, and PTSD.  Isn't that a kick?"  Probably more relevant is the concrete way a diagnosis seems to account for one's frightening instability.  Better to be "ADHD" than merely a scattered teen who can't study.  The former confers scientific legitimacy, promises specific treatments, and even justifies entitlements such as extra testing time in school.  These labels can also ease personal responsibility and humiliation, as when outrageous social behavior can later be attributed to Bipolar Affective Disorder or some other "chemical imbalance."  Despite the persistent stigma of psychiatric diagnosis, these labels have enough psychological and practical advantages that some patients wear them proudly.

The downside to all of this is that individuals can become known, even to themselves, by impersonal diagnostic labels.  Knowing oneself as PTSD, ADHD, and/or OCD can dehumanize.  It can prematurely close off inquiry and self-reflection.  And DSM diagnoses do not actually explain anything; they are better conceptualized as statistical categories.  Such diagnoses are useful tools, but like all tools they can be misused.

If I accused you of being a Martian...

Cross-posted from "Sacramento Street Psychiatry". In dynamic psychotherapy, patients often say how hurt and victimized they feel as a result of unkind judgments or criticisms by others:

"My coworker called me a hypocrite!"

"My mother told me I neglect her by not visiting enough."

"My husband complains I'm too self-centered."

Although sharing such complaints with a caring listener is basic human nature, in therapy it is also recognized as a defense mechanism called externalization. A fundamental tenet of psychotherapy is that change comes from within. The hurtful coworker, mother, or husband is not present in the room, and cannot be influenced directly by the discussion. It is the patient's reaction that can be examined and perhaps modified.

I tend gently to move things along in therapy, as opposed to letting them unfold at their own pace. I often question this in myself, sometimes wondering if I am too results-oriented. On balance, though, I believe it saves time, money, and tedium for both of us if I focus on issues that can actually make a difference. With this in mind, I don't let externalizations just sit there. I playfully illustrate how harsh judgments only sting if the patient accepts or endorses them at some level: The hurt is really self-criticism, and the solution is really a new self-appraisal.

If I accuse you of being a dirty rotten Martian, it isn't apt to have much impact. You may question my sanity, but you are not put on the defensive or moved to offer a spirited rebuttal. Nor do you engage in sober soul-searching to assure yourself I'm mistaken. You already know you are not a Martian, so the putdown rolls off your back.

In contrast, what if I accuse you of being selfish? This charge is harder to dismiss. We are all selfish to some degree; it's a judgment call where to draw the line between self-interest on the one hand and self-sacrifice on the other. Moreover, as Sigmund Freud describes in Civilization and its Discontents, humans are able to live together in society because we repress many self-gratifying urges into the unconscious. We are, in other words, more selfish (and narcissistic, and greedy, and hypocritical, and childish...) than we like to think.

The criticisms that sting are the ones that stir up our own self-doubts. Maybe we are hypocritical, neglectful, self-centered. Perhaps our shameful defect has been exposed. This is what calls up anxiety, reactive anger, and defensiveness.

Such self-criticism is unpleasant when made conscious in therapy. Yet this is the path toward change. For the problem is not in the external world after all. It resides in the mind of the person in the therapy room, a person who now more clearly sees where his or her troubling feelings originate.

I really do use the Martian example all the time in my work with patients. It's a thing of joy to watch how something so apparently frivolous can shift the focus from unhelpful externalization to honest insight.

Bull in a china shop

Reposted from Sacramento Street Psychiatry. Sometimes an unruly character disrupts the surrounding peace and quiet.  Loud, gruff words and ill-considered behavior mar the scene.  Onlookers cringe, awaiting the impending destruction.  For this beastly fellow is bound to break something: wreck a friendship or relationship, make a workplace intolerable.  All the worse if the setting harbors sensitive souls with feelings easily hurt.  It's a disaster waiting to happen.

We might say this person is a "bull in a china shop."  In this image a powerful animal threatens fragile items of great value.  Its untempered impulses — hunger, lust, anger — may bring the edifice crashing down at any instant.  Even the natural movements of a relatively calm bull may clumsily destroy order and beauty all around.  The message is clear.  This bull needs to be controlled, tranquilized, restrained if necessary.  Or magically turned into something innocuous, a house-cat perhaps.  As a last resort, it must be led out of the china shop without delay, before more damage is done.

Certainly there are interpersonal situations described very aptly this way.  However, in my psychotherapy work I've repeatedly encountered this scenario turned on its head.  I've begun to look at the phrase differently: Maybe the bull isn't always the culprit.

The phrase "bull in a china shop" usually implies that the china shop was there first.  The bull wandered in uninvited.  But suppose we set up the scene another way.  Picture a bull grazing in an open field.  Yes, it's a big powerful animal, and maybe it's a bit clumsy.  But it isn't hurting anyone; it is living in peace.

Then imagine someone sneaks up on this bull — and builds a china shop around it.  The animal suddenly finds itself constrained, unable to move without hearing the crash of broken porcelain.  Its natural movements are now seen as destructive, as the china is surely at risk.  Yet it isn't quite right to blame the bull.

In human relationships, the person with socially disturbing behavior hasn't always caused the problem.  This manifests most obviously in work with children, who frequently express parental distress through their own misbehavior.  Even in adults, an apparently calm and mature person may quietly stir up someone else, who then becomes the "identified" patient (a term from family therapy implying that one or more other parties, equally worthy, evaded this identification).

In individual therapy, patients often build a case in calm, reasoned tones that their partners, close relatives, or coworkers are unruly, uncaring, even beastly.  They describe emotional ruffians who threaten them without cause.  It can take months, or longer, before a patient's own role comes to light.  This may take the form of passive-aggression, i.e., goading the other into lashing out.  [Some links describing passive-aggressive behavior.]

There is no small measure of passive hostility in building a china shop around a bull.  All too often we observers arrive late upon the scene, only to witness the wild animal haplessly bumping into fragile dinnerware.  It can take a long time to realize that the bull was just being a bull, and that the root problem was the apparently innocent bystander who constructed a china shop the bull was almost sure to topple.