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Maui 2008 178

One of the sticking points with some folks in AA is the step that says you will surrender to a power greater than yourself. Surrender is not the American way, or maybe more accurately, not the Protestant work ethic way. You must give 110% even though that is not really possible. For example in running, you bonk before your glycogen levels fully deplete. Your brain takes care of you by telling you to take it easy. Think of what happens to the motherboard on your computer when you overclock the processor to increase power. You overheat and fry it. And yet, if we don’t succeed we are encouraged to keep trying to the point of attempting to get out of a hole by continuing to dig. I think of it as a Vietnam syndrome – just keep sending troops and keep bombing and victory will inevitably come. Somehow we didn’t learn much from that experience.

In Chinese philosophy there is the concept of wu wei or nonaction, trying not to try, or effortless effort. A similar state in western psychology is the flow state described by Mihály Csíkszentmihályi. It is when you are in the zone. You cannot force yourself into flow or wu wei, you have to let go – surrender – and just be with it. When you become aware you are in that state, you are out of the moment and you lose it.

We have known for a long time that outcomes for people diagnosed as mentally ill have better outcomes in third world countries than in the west. People are treated differently in the “less advanced” cultures. In the west, we also put labels on people and then try to force them to behave in what we consider socially appropriate ways. For over 50 years the work of Brown, Birley, Vaughan, Leff, Wing and others found that the expressed emotion in families was a primary causative factor in rehospitalization in psychiatric facilities. Behaviors that got on family members’ nerves were more likely to cause trouble than the psychiatric symptoms. I came across their research in the late 1970s while working on a rehospitalization factors study at a state hospital. Expressed emotion was not touted as a factor in causing mental illness – no schizophrenogenic mother theory. It was just that when someone is criticized in certain ways, even when caring and concern are at the heart – sometimes feeling judged and pushed does not lead to the outcomes that are desired by the one expressing concern. And that is true regardless of whether one is ill or not.

In the recovery movement, the shift is to treat people with dignity and respect. Ezra E. H. Griffith has edited a comprehensive book that covers issues like involuntary commitment. It is called Ethics Challenges in Forensic Psychiatry and Psychology Practice. It is an excellent read addressing all the variables we face in social control when we treat people with psychological problems differently than those with physical problems, for example, diabetes.

It also got me to wondering about how wu wei might come into being when treating those considered chronically and seriously mentally ill. The July 1, 2016 Invisibilia episode has an intriguing take. You can listen to it here. It is called The Problem With the Solution. It starts with an American dream kind of product invention, and then looks at solutions in mental illness. It reminded me of Scott Miller saying that once something is defined as a problem, it gets worse. Could a reframing, a surrender into acceptance, be one solution? The podcast looks at the story of Ellen Baxter and her search for understanding with her family. That search took her to college and to Geel, Belgium, where people diagnosed with mental illness live with foster families who accept them for who they are and have no idea of the person’s diagnosis. Does Geel, Belgium have a humane, kind and respectful solution? Baxter began a project in New York called the Broadway Housing Project. It is not only humane, it is also cost effective. Also mentioned is Jackie Goldstein and Voices of Hope. You can read more about Jackie Goldstein and Voices of Hope here. Be sure to listen to the bonus story of William Kitt at Invisibilia. Information about the Broadway Housing Project and Ellen Baxter is at http://www.broadwayhousing.org/. There is also this 1993 New York Times article – https://www.nytimes.com/1993/12/19/magazine/ellen-baxter.html.

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Kona Hawaii 2013 116

I remember Dr. Peter Derks, my very first psychology professor, many years ago discussing a study in which people were asked to find patterns in flashing lights. Lights would flash in a sequence and participants were supposed to figure out the pattern so they could predict which light would flash next. What the participants didn’t know was that there was no pattern. The lights were programmed to flash in a random pattern. In every case, however, people found a pattern. When they were ultimately proved wrong, they would typically say, “now I see what you’re doing,” and would change their theory to a different pattern. No one ever figured out that there was no pattern, it was all random.

The NPR podcast, Invisibilia, recently did a story about patterns in the context of trying to predict behavior. One story was about a woman who had a history of abuse and arrests. She had turned her life around and was trying to become a lawyer in Washington state. Her appeal went to the state supreme court, and her attorney was a man who had convictions of bank robbery. Another story was about a Princeton study that used longitudinal data to try to predict outcomes in children. The researchers, despite massive amounts of data and coding efforts were not able to predict outcomes. You can listen to the podcast at https://www.npr.org/podcasts/510307/invisibilia (it is the March 18, 2018 podcast) or you can read the transcript here. People long for patterns and predictability and typically feel very uncomfortable with randomness. With randomness you can’t predict what will happen next. And life just has way too many variables to be completely predictable.Our brain takes shortcuts to give us the comfort that we can predict things. We inherently look for patterns. It enhances our chance at survival. It is part of evolution. It also gives us a sense of self, of who we are. We are those patterns we fall into.

Michael Puett, a professor at Harvard, and Christine Gross-Loh wrote a book called, “The Path: What Chinese Philosophy Teaches Us About the Good Life.” Rather than looking inside for our “authentic true self” we are urged to “recognize that we are all complex and changing constantly. Every person has many different and often contradictory emotional dispositions, desires, and ways of responding to the world. Our emotional dispositions develop by looking outward, not inward. They are not cultivated when you retreat from the world to meditate or go on a vacation. They are formed, in practice, through the things you do in your everyday life: the ways you interact with others and the activities you pursue. In other words, we aren’t just who we are: we can actively make ourselves into better people all the time.” Every moment can be a moment of redemption or a moment of damnation. For all of us. Puett says that Zhuangzi, a Chinese philosopher of the Warring States period, said that labeling yourself is dangerous. It limits you. Saying you are an inherently shy person limits you to being that, you become stuck in that pattern. Instead, you can look at each moment for what you can become. We are not static beings.

That moment of becoming reminds me of solution focused therapy and narrative therapy. You start with small steps, like a small snowball at the top of a hill that gets bigger as it rolls down. The problem is outside yourself, and does not define you. Instead of staying with your past patterns and stories, you look at how you would like to be. It reminds me of flow – you become one with the moment you are in. But that takes practice. Humans tend to fall off the Way or Dao. We get caught up in thinking and patterns and ruts. Joseph Campbell, when interviewed by Bill Moyers on the Power of Myth, spoke about the Coptic Christians for whom the everlasting life was living forever in the moment – transcendence. Confucius used rituals to help us get there.

Chance life encounters with their randomness play a large roll in our lives, too. That can be for better or for worse. The better are situations like that if Theodore Geisel, or Dr. Seuss, who had given up on publishing his first book and planned to destroy it. That changed with a chance encounter on a walk home. You can read that story here. For worse could be an instance of just being in the wrong place at the wrong time. I remember years ago a man driving home from work, just as he did every week day, was killed when a car, driven by an adolescent girl and friends, went airborne with the front end coming down into his windshield and killing him instantly. Albert Bandura wrote an excellent article on chance life encounters in the APA Monitor back in 1982. You can read it here.

So in this life, with all its messiness and randomness and chaos, how can be live in a way of growth and loving kindness? How can we live in the present so that we are not captured by the past, but have a chance at a better future? How can we change our relationships into skillful ones? How can we flourish? The Path gives us some practical ideas from the Chinese philosophers whose ideas have been found to be supported by neuroscience.

I think a part of changing and just being in this life is to be comfortable with that randomness and ambiguity. We learn that going with the flow is being open to the results of that butterfly flapping her wings off the coast of Africa, and we adapt and adjust as best as we can. That may go against our nature of desiring predictability and a world of where everything is easily judged right or wrong, good or bad, and we always know what comes next. Rather than judge harshly and condemn or overly praise and think that something is solved for good, we look at how skillful we are and how we can improve that. We have a sense of curiosity. The Chinese philosophers all sought to teach us how to be decent people, each in their own way. It is a constant life long process, and our skill levels vary from moment to moment. The philosophers from Confucius to Xunzi all have ways of reaching a place where we automatically find and live the Way. But for all the teachings, there is an inherent paradox. The harder you try, the more difficult it becomes. In Chinese, the process similar to flow is “wu wei” or effortless effort. Edward Slingerland gives a good overview.

2015 Bar Harbor

We unite ourselves and divide ourselves with words. We not only define but give emotional meaning to things with words, and you often can tell the importance of something by how many words there are for it in a language, a classic example being the number of Inuit words for snow.

Political correctness often comes up in the discussion of the evolving of our language and how we frame our culture. The discussion is often disingenuous, for the same philosophical group that disparages the move to change the name of the Washington professional football team name as political correctness gone overboard forced the Cincinnati professional baseball team to change its name to Redlegs for a time in the 1950s so they wouldn’t sound communist. That was also the time that the US national motto was changed from “E Pluribus Unum” (“Out of the many, one” – an inclusive unifying phrase) to “In God We Trust” in an effort to prove we were not and to divide us from “godless communists.” This was done despite the constitutional separation of church and state. In Virginia, Jefferson’s Statute for Religious Freedom had major supporters in the Baptists who did not want to pay taxes to support the official government religion of the Church of England. Those who most speak out against Sharia law ironically want to force their own brand of Christianity (and there are many brands and denominations) on others. They are doing exactly what they say they oppose, but it is okay because it is their brand. To oppose it is to be politically correct in a “bad” way. Those thoughts are further stirred up by talk radio and the disinfotainment branches of cable TV news and propaganda sources that masquerade as news.

One of the Founding Fathers of the US was a physician named Benjamin Rush. One of the things he is remembered for is declaring that addiction to alcohol is a disease. There has been an ongoing debate about whether addictions and other issues of behavior are diseases or not. The labels have changed over the years, and what is and is not a disease or a disorder has changed over time as well. Trying to decide what to call people we see as having these problems changes, too. Do you say, he is an addict? Or do you say he is a person with an addiction? Do you say he is a schizophrenic? Or do you say, he is a person with schizophrenia? Does it matter? Is it all just political correctness? Take a deep breath for a moment, and think. What do you call a person with cancer? Do you call them a cancer patient, a person with cancer? No one that I know of calls them a cancerite or some other word that implies that they are the disease. Now there are conditions like diabetes and hemophilia that do have words for a person with the condition. Do you feel a different emotional reaction to the words “alcoholic” and “schizophrenic” than you do to “diabetic” and “hemophiliac”? Would you feel differently towards someone called a cancer patient or a cardiac patient than you would schizophrenics and diabetics? Would that feeling change according to how you think they became ill? Did it just happen, or did they bring it on themselves by smoking or diet, or was it some environmental contaminant beyond their control? Does that change how you feel?

Our language shows in a very strong way how we determine and express our values. In a diverse culture, there are different values and different linguistic ways of expressing those values. One can rigidly hide behind lazy shortcuts like “political correctness” and somehow feel smugly superior when belittling something as politically correct. Or one can look more deeply at the language and try to see what values that language expresses. One thing working with families has taught me over the years is that families function better when the members treat each other with respect and compassion. Language and the values that language expresses and teaches can help a culture function more positively when it has compassion and respect as fundamental parts of its foundation. Remember the principles of taiji – softness overcomes hardness, and flexibility overcomes rigidity. In the West, another way of expressing that is that a soft answer turns away anger. The emotions of language are contagious for better or for worse.

The American Medical Association voted not long ago to classify obesity as a disease.  The intentions were good, for obesity and the associated health problems, do need attention. There are problems with this, for example if one uses only body mass index to diagnose, then an individual with heavy musculature could conceivably be diagnosed as “obese” when clearly that is not the case. Some, such as National Review, write that this is another attempt to lessen personal responsibility and allow government to enter into our lives and our bodies.

Physicians’ attempts to change what were at one time called “conditions” or “failings” or other terms into “disease” is nothing new.   You can read an excellent summary on the evolution of the term “schizophrenia” in the November 2011 Schizophrenia Bulletin.  The article quotes Berrios, “… schizophrenia research can be described as a set of research programs running in parallel, each based on different concepts of disease, mental symptom, and human mind.” For an overall critique of schizophrenia as a disease, Models of Madness is a good start. Alcohol dependency has been defined as a disease for decades. Dr. Benjamin Rush, a founding father of the United States, is credited with declaring that alcoholism is a disease. The research of E. M. Jellinek aoubt 60 years ago is credited with giving this diagnosis credence. David J. Hanson, PhD, of SUNY-Potsdam, gives a thoughtful critique of the disease model at http://www2.potsdam.edu/hansondj/Controversies/Is-Alcoholism-a-Disease.html.

Mosher et al in Models of Madness review the relationship of causal beliefs to attitudes.  While at times part of the motivation to define something as a disease is to lessen the stigma, often the reverse happens.  John Read and Nick Haslam wrote the chapter, “Public Opinion.” They cite numerous studies that find that when something is defined as a biological illness, the stigmatization increases. “A belief in categories that are discrete, immutable, and invariably rooted in a biological abnormality reflect the medical model’s essentialist view of mental disorders as ‘natural kinds’. Viewing mental disorders in this essentialist fashion is associated with prejudice along multiple pathways.  Believing in immutability may promote pessimism and avoidance. Believing in discreteness promotes the view that sufferers are categorically different, rather than sharing in our common humanity. These essentialist beliefs form a toxic ensemble.” This unintended consequence should be no surprise. It is rather common among diseases for which there actually are lab tests to diagnosis. Several members of my family, including my father, had tuberculosis. People, including family members, shied away for fear of catching the disease. Virginia mandated testing and x-rays for immediate family members (despite negative tests) from my earliest memories until about college age.  Susan Sontag wrote about cancer in Illness as Metaphor, and how there was an exception in confidentiality laws at the time for one disease due to stigma, and that was cancer. She later wrote about AIDS as well. I once visited Kalaupapa, which was a leper colony on Molokai. There were still people living there, now cured of Hansen’s disease. These folks also took you on the tour of the site. You got to hear stories about how people who were even suspected of having the illness were snatched off the street and taken here, banished from their lives, and isolated from friends, family, and home forever. Kalaupapa is a very moving place to visit. You can most likely think of other diseases with stigma, perhaps even some you fear. Based on our history as humans with a fear of disease, it is remarkable that anyone thought that defining a behavior, any behavior,  as a disease would make it less stigmatizing. In some ways, it is metaphorically throwing gasoline on a fire hoping this time a miracle will happen and the liquid will extinguish the blaze.

I think there are at least two issues at the foundation of this disease problem. And this excludes the political and economic and ego issues associated with the businesses of academia and treatment programs and medicine and pharmaceutical companies. That is a whole other thing. The first issue is thinking we know what a disease is, and that we all agree on what that means. But at the foundation of these troubles is deciding just what is a disease. That is how diagnoses got started – when we research and treat or even just talk about a condition, we need to know we are talking about the same thing. Let’s define it. Unfortunately in behavioral health, from the start egos and later egos and money were involved and muddied the good intentioned waters.  Berrios mentions the different concepts of disease above in the study of schizophrenia.  A quick web search gave me many definitions for disease, among them:

  • a disorder of structure or function in a human, animal, or plant, esp. one that produces specific signs or symptoms or that affects a specific location and is not simply a direct result of physical injury.
  • an impairment of the normal state of the living animal or plant body or one of its parts that interrupts or modifies the performance of the vital functions, is typically manifested by distinguishing signs and symptoms, and is a response to environmental factors (as malnutrition, industrial hazards, or climate), to specific infective agents (as worms, bacteria, or viruses), to inherent defects of the organism (as genetic anomalies), or to combinations of these factors
  •  A pathological condition of a part, organ, or system of an organism resulting from various causes, such as infection, genetic defect, or environmental stress, and characterized by an identifiable group of signs or symptoms.
  • A condition or tendency, as of society, regarded as abnormal and harmful.
  • Obsolete Lack of ease; trouble.

Pretty much anything out of the ordinary can be called a “disease.”  I remember folks going back 30 years who have justified the disease model in mental health and substance use by relying on the last – the obsolete – definition of dis-ease. These days, the term would be unease. So when people argue about what is a disease and whether something specific is a disease, they may be talking about very different concepts.

The second issue is, I think, with the problem of defining words and giving them great power. Steve deShazer was right, that words were originally magic.  But we use words to define words, and the definitions are circular. They have to be, and they are imperfect. The words defining an apple in the dictionary will never give you the experience of an apple.  Even experiencing one apple will not give you an idea of the taste and look and fragrance of all apples, or of the potential of apples or of the creation and life and death and return to the earth of an apple. Putting a label on an individual will not give you an experience of that individual. Being with that individual in one situation will not give you the experience of the whole ever changing person. Words have the power that we give them. We need to be careful.  I remember years ago in graduate school reading about a study in which individuals with no psychiatric problems gained admission to mental hospitals, and then just acted as themselves. Other patients caught on rather quickly that these folks were not mentally ill, but staff – not so much. The individuals took notes about their time in the hospitals, and nursing staff charted that they were exhibiting “writing behavior.”  David Rosenhan writes about the study here.

I will leave you with two quotes from Alan Watts, and also the remarkable story of Eleanor Longden in her own words.

“We seldom realize, for example, that our most private thoughts and emotions are not actually our own. For we think in terms of languages and images which we did not invent, but which were given to us by our society.”

“Trying to define yourself is like trying to bite your own teeth.”

Eleanor Longden: The voices in my head

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