Does Cognitive-Behavioral Therapy Apply to Campus Politics?

Note: Usually, when I write about any remotely politically-charged topic, I make sure my arguments are very clear in my mind and supported by 9000 citations first. This isn’t the case with this topic, which I’m still forming ideas about. I’m posting this because I’d love to hear feedback/counterpoints from cognitive-behavioral therapy (CBT) and social justice perspectives: kathrynhgordon@gmail.com.

university-105709_1280

I was recently on Jesse Singal’s podcast, and he asked thoughtful questions about the applications of CBT to campus culture war issues. Apparently, a side effect of asking me good questions on a podcast is that follow-up blog posts occur (well, it’s happened twice so far, anyway).

Here are my current, still-forming thoughts about whether CBT should be applied to college students making claims about politically-related offenses and psychological harm. My points are based on a variety of different arguments I’ve heard and are not directed at particular people/texts, though I believe this is the original article applying CBT in this way.

1. CBT is excellent and improves the lives of a lot (but not all) people struggling withBurns.jpg mental health issues. I’d love for all college students to read David Burns’ self-help CBT book, Feeling Good: The New Mood Therapy (which is referenced in the original article on this topic). I read it in college, found it eye-opening, and then proceeded to recommend it and loan it to countless people since — including undergraduate students who I taught when I was a professor. Seriously, ask anyone who knows me — I have probably recommended that book to them. Not all students find it helpful (which is consistent with research on any treatment modality), but some really do. However, it’s important to recognize that CBT is designed and scientifically-tested as a treatment for people who are having mental illness-related distorted cognitions and thinking errors. It does not focus on societal stressors related to healthcare access, income inequality, rights, or prejudice, and it doesn’t offer solutions to those issues either. My concern is that placing thoughts related to these issues in a CBT framework reinforces some individuals’ default position that people talking about experiencing prejudice or feeling upset about political issues are exaggerating. Within a therapeutic context, these complexities can be addressed with nuance. Outside of that context, I worry that it bolsters notions that people can and should just think their way out of these types of stressors. This NYT article is about an illustrative real life example of how this kind of disbelief or minimizing default can lead to negative consequences.

2. Relatedly, I’m wary of using CBT as a method for ‘correcting’ other people’s thoughts and feelings about offense or harm unless I’m the person’s therapist (and even then I’m cautious) for the following reasons:

Humility & AccuracyIf you think someone is overreacting to a politically-related incident, you can just plainly state that as your appraisal of the situation instead of using CBT language (e.g., calling it catastrophizing or emotional reasoning). When you say someone’s thinking is distorted, the assumption is that you know for sure that they’re overreacting and also that you know why they are (and that is mindreading). I don’t see the incremental value of using CBT terms in situations where you don’t know much of the context, unless it’s to tone down the fact that you’re making a judgment about the accuracy of a person’s thought by framing it as a concern about their mental health.

EffectivenessIn the self-help version of CBT, a person learns tools for investigating their own distortions and thoughts. In therapy, it’s a collaborative process, where the therapist hears the person’s point of view and guides them through the steps of evaluating their thoughts in a compassionate, contextualized process. By design, CBT helps people arrive at reframed thoughts that ring true for them. It can be hard to get to that place in therapy — it seems much harder to get to that place through some of the other methods I’ve observed (articles/posts referring to students’ behavior as evidence of their fragility). To be clear, I’m not saying that thought errors don’t happen in certain college campus situations — I’m just saying I don’t see how motivated the average college student would be to evaluate thinking errors when presented with them as a sign of their fragility.

Ignoring Real Problems Where They ExistAs I wrote about before, I think that disproportionate focus on students’ purported lack of resilience ignores the valid reasons for their actions. If students get painted with too broad of a brush and are characterized as simply being unable to tolerate opinion differences, then it distracts from points of legitimate concern about the spread of ideas that perpetuate social inequities. When therapists disagree with their clients’ approaches to situations, they motivate change by looking for and validating the truth in what the client is saying and collaboratively generating ideas about adaptively achieving their objectives.

Furthermore, there’s a long history of people from marginalized groups being misdiagnosed and poorly treated within mental health fields (e.g., 12). Broadly applying cognitive distortion framework in a public way doesn’t allow for a culturally appropriate framework that therapists are trained to use in treatment. Without that context and training, people might minimize or deny others’ valid experiences–which could be harmful to their health.

In conclusion, there are helpful elements in cognitive-behavioral therapy that apply to particular types of problems — especially when depression- or anxiety-related thinking errors are present. I have reasons to doubt it would generalize beyond what it’s been tested on and designed for, but could be convinced otherwise with empirical data.

How Psychologists Capture the Complexities of Mental Illness

When it comes to understanding and treating mental illness, clinical psychologists must strike a balance between grouping people with shared characteristics together and recognizing people’s individual paths, circumstances, and needs. Below I’ve described some of the models that clinical psychologists use to reflect these complexities.

1) Biopsychosocial Model

Most modern psychologists understand that mental illness is the result of both nature and nurture. Accordingly, biopsychosocial models map out biological, psychological, and social risk factors for mental health outcomes and highlight potential intervention points. This model is so prominent that clinical psychology graduate programs require education in human development, individual differences, and biological, cognitive, affective, and social aspects of behavior, and you can’t become a licensed psychologist without passing a formal test on these topics. The idea is that mental health outcomes result from the interplay of biological, psychological, and sociocultural factors and that different people arrive at outcomes through different combinations of factors. Here’s a sample I constructed from some suicide risk factors:

biopsychosoc

2) Diathesis-Stress Model

People with identical genetics (i.e., monozygotic twins) and people with shared stressful events (e.g., witnessing the same violent act) can have different mental health outcomes. For example, many people with family histories of eating disorders will not develop eating disorders. Likewise, many people who have been bullied about their weight will not develop eating disorders. A diathesis-stress model of eating disorders explains this by saying that a person must have both a vulnerability (e.g., a genetic predisposition) and a significant stressor (e.g., weight-related bullying) to develop an eating disorder.

DSM

3) Multifinality and Equifinality

People who experience a similar event (e.g., trauma) can have disparate outcomes that depend on other factors (e.g., financial resources, societal views of survivors). This is called multifinality. Meanwhile, people with similar outcomes (e.g., posttraumatic stress disorder) can arrive there via distinct pathways (e.g., surviving sexual assault, a car accident, being the victim of gun violence). This is captured with the term equifinality.

EM

4) Distal vs. Proximal Factors

Most research on mental illness focuses on a few risk factors per study. Organizing findings across studies can feel like fitting puzzle pieces together to create a holistic picture. One way to do this is by grouping risk factors in terms of how far in time (distal) and how close in time (proximal) they are to the onset of mental illness. For example, strategies for reducing distal risk factors for adult depression may include public policy efforts to prevent childhood maltreatmentincrease access to quality health care, and decrease discrimination. Meanwhile, therapy for individuals with depression may focus on more proximal factors (e.g., enhancing coping skills, increasing social support, behavioral activation).

distal proximal

5) Nomothetic vs. Idiographic

I highly recommend this article by Beltz, Wright, Sprague, and Molenaar (2016) for detailed definitions of these terms:nom idioFor example, imagine that a client gets diagnosed with obsessive-compulsive disorder (OCD). In order to figure out the best way to help, a therapist begins with nomothetic information (e.g., the diagnosis) to select a treatment. A randomized clinical trial suggests that a type of cognitive-behavioral therapy called exposure and response prevention (EX/RP) leads to significant improvement among 80% of people with OCD after 17 sessions. Based on available information, EX/RP is a good place to start. However, it’s possible that the client will be among the 20% of people who don’t respond to EX/RP. Therefore, therapists must also pay attention to idiographic information after initiating treatment (e.g., by regularly assessing the client’s OCD symptoms over time). If the client’s not responding to therapy, the idiographic data signal that the therapist must figure out why and make appropriate changes.

ni

For more information on nomothetic and idiographic approaches, check out:

Clinical Practice as Natural Laboratory for Psychotherapy Research: A Guide to Case-Based Time-Series Analysis

Clinical Versus Actuarial Judgment

Single-Case Experimental Designs for the Evaluation of Treatments for Self-Injurious and Suicidal Behaviors

What Can the Clinician Do Well?

I’ve described frameworks that clinical psychologists use to understand people’s mental health needs at multiple levels while respecting their individuality. The dedicated people working hard to alleviate suffering in the face of these challenges give me hope for the future of the field.

img_0818-e1549833493956.jpg

Brother Ali’s Song about Losing His Dad to Suicide

I’ve seen Minneapolis-based rapper Brother Ali in concert several times, and he strikes me as someone who’s as kind as he is talented. When I told him at a Chicago show that I had previously chatted with him in Orlando, he tried to remember me. He told me that he doesn’t recall faces due to albinism-related vision issues, but he recognizes people through reminders of previous conversations. He rapped about his experiences in “Us”: And I go with the feeling from the start/Blind in the eye, so I see you with my heart/And to me all y’all look exactly the same/Fear, faith, compassion and pain.

All of this is to say that I’m a Brother Ali fan and my expectations were high for his 2017 album, All The Beauty In This Whole Life. I think it’s a musical masterpiece, and “Out of Here” is a standout song. The lyrics are a detailed expression of his feelings and thoughts after losing his dad to suicide. In this post, I included all of his lyrics (in bold) and my comments (in italics) with some links to relevant research.

I recommend watching his performance of the song before reading the rest of the post:

Okay so it might appear
To an outsider that you found your way up out of here
They’re saying you died of suicide
People who are suffering may view suicide as an escape from a painful life. I like how Ali phrases the third line, because it removes the stigma associated with other phrasing (e.g., commits suicide).
That’s the last thing I want to hear
They tell me that it’s hardly fair to blame myself
What a hell of a cross to bare
You didn’t say it in your letter
But the fact that I failed you is loud and clear
Suicide can be a particularly painful kind of death to grieve because 1) it means someone you love was deeply hurting and 2) there may be more of a sense that you could have prevented it, if only you had acted differently in some way. It’s a common response for people to tell you that someone’s suicide is not your fault, and yet, it can be hard to refrain from blaming yourself for not stopping the person.
Found out the amount of fear
You would drown when you found yourself naked staring down a mirror
And partners are supposed to lay the cards bare
I left you playing solitaire, and I promise you that I’m sincere
When someone dies by suicide, it might feel like there was a misunderstanding or even a kind of dishonesty between you if you didn’t know the person was contemplating suicide. I think Ali is saying that his dad might have been trying to tell him how he felt (‘lay the cards bare’), but that Ali felt like he failed him by leaving him ‘playing solitaire.’ Powerful imagery.
If you’re looking for some judgment, you won’t find it here
Let’s be honest here
I can’t say I’ve never known that kind of despair
When the clouds appear, how’s life fair
Some people erroneously perceive people who die by suicide as selfish or weak. However, Ali feels compassion and humbly links it to his own experiences. He may also be fearful about his own future (e.g., will his suicidal desire increase to the levels that his dad’s ultimately did?).
I just want to draw you near
As he sorts through the different feelings, there’s a basic desire just to be close to his dad again.
Not to make it about me, but how could you check out
Before you really allowed me a chance to sit down and hear?
I think I would’ve listened
Or were you saying it all along and I just missed it?
You sang your swan song, we all dismissed it
Ali acknowledges that the suicide isn’t about him, but feels a frustration about his father leaving without trying to ask Ali for help first. He then changes course and tries to look for signs that his dad *tried* to reach out, but that Ali missed or ignored it.
Because you filled the room with laughter
I watched when you thought no one was looking at you
In hindsight, I wonder where your smile went
When the party ended and you swallowed it
I saw you swallow it
Sometimes, people who have lost someone to suicide say they saw it coming, but others feel completely shocked. It can also switch back-and-forth in the mind of a person as they try to make sense of it.
Okay so it might appear
That you took yourself up out of here
How many cries soak through your disguise
Before you drown in your silent tears?
Okay so it might appear
That you took yourself up out of here
How many times can you fight for your life
Before you throw that white flag up and volunteer? (x2)
Here, Ali seems to be trying to figure out the threshold that was crossed before his dad killed himself. I don’t know if this is Ali trying to understand if his own life obstacles and past suicidal ideation might ever exceed that threshold or if he is trying to understand his dad’s experience better (or both).
I’ve had car accidents
Where everything is slow motion no matter how fast it’s happening
Every second that pass stretches so that you can watch it unraveling
But can’t always react to it
Your whole life might flash before your eyes
The minute when you transition to the other side
But what can actually happen in that time?
In-between the leaping and the moment you collide
In-between the trigger and the blast
In-between you let go of the wheel and you crash
In-between the moment when you swallow the last pill in the bottle
Turn out the lights, roll the dice on tomorrow
Is there a moment to reflect, can there be regret?
Is there a wait, not yet, let me reset?
Or is it just too painful to accept?
That maybe death just seemed best
I think Ali is trying to imagine what his dad was going through at the time he died by suicide since he cannot ask him about it. He’s wondering if he crossed his dad’s mind or any reluctance emerged that could have prevented his death. Or was it more like an uncontrollable-type of experience where he felt like he was watching himself but could not change the outcome?
Suicide prevention researchers, such as Thomas Joiner (1,2), have argued that an innate drive for survival and fear of death saves the lives of many people who desire suicide. I have heard Joiner describe this as a ‘flinch’ that people might experience right before or during a suicide attempt. He has presented compelling anecdotal evidence of this through stories of people who survived suicide attempts. Kevin Hines, a suicide attempt survivor from the Golden Gate Bridge, said he felt instant regret after he jumped. Along with others, suicide prevention researcher Mike Anestis, has proposed that this window maybe an opportunity to prevent some suicides through means restriction during high risk periods
I heard this as Ali arguing for not taking one’s life, even in the face of repeated, seemingly unjust hardships…’you can go down swinging.’
Okay so it might appear
That you took yourself up out of here
I’m trying not to resent you
But you left me defenseless in the life we share
Every man before me in my fam died by his own hands
How am I supposed to understand my own role in the plan
When nobody who grows old stands a chance?
Ali lost both his dad and his grandfather to suicide. He’s wrestling with sympathy for his dad and his own feelings about being left behind.
What about this mysterious dance
Made you cut the cord to the curtain in advance?
But these are questions I can only ask
The person looking back in the looking glass
Ali recognizes that he is full of questions that now must go unanswered.
I’ll close by saying that I am truly sorry if you’ve lost someone to suicide – this post is dedicated to you. I’m especially thinking of a friend who is going through this now. Research by Julie Cerel and colleagues suggests that each suicide affects a large number of people (even larger than previously thought). It’s imperative that we increase the effectiveness of suicide prevention efforts. If you need support, please consider some of the resources below.
Resources
You can find a therapist through the Association of Behavioral and Cognitive Therapy, and you can find a support group for survivors of suicide loss through the American Foundation for Suicide Prevention website.
The National Suicide Prevention Lifeline has an online chat option, and their phone number is 1-800-273-TALK.

Gender Dysphoria & Suicidality in Laura Jane Grace’s Memoir

ljg

Laura Jane Grace playing with Against Me! in Fargo, ND in 2017

I’m a big Against Me! fan, and I recently re-read Laura Jane Grace‘s captivating memoir. I loved learning the stories behind the lyrics and catching Grace’s clever references, like when she said that NoFX never had to wait at the end of the longest line at Warped Tour. I grew up in the Florida punk scene during the late 90s/early 00s and enjoyed the nostalgic recollections throughout the book (e.g., making free copies at Kinko’s, reading zines, and going to concert venues like The Edge). I could write a super-long post about the many poignant parts of the book (see below for a picture of all the pages that I marked to revisit later), but there are people who do that professionally, so I’ll leave it to them.
book

Instead, I’ll focus on the angle that I’m more familiar with: discussing mental health research in the context of people’s stories (e.g., 1, 2, 3). Grace identifies as a transgender woman and has described her gender dysphoria as a deeply distressing experience resulting from a misalignment between her self-perception and physical body. Her book opened with her earliest memory of gender dysphoria, which occurred at age 5 while watching Madonna on TV:

Her dirty blond hair was moussed and frizzed to perfection. Her neon and black clothes were ripped and torn to accentuate her curves. Her chunky bracelets and necklaces sparkled and jangled against her arms and neck as she moved to the beat. I reached out my hand and touched her on the screen. That’s me, I thought, clear as day. I wanted to do that. I wanted to be that. 

This sense of wonderment was cut short by confusion. Suddenly I realized that I would never be her, that I could never be her. Madonna was a girl; a confident symbol of femininity, singing and dancing onstage in a short skirt and high heels. I was just a small boy, living in a ranch house on an Army base in Fort Hood, Texas.

My father’s name was Thomas. My uncle’s name was Thomas. My cousin’s name was Thomas. And I was born Thomas James Gabel, the son of a soldier, a West Point graduate who never went to war. That was the name written on my birth certificate, but I never felt that it suited me.

Beginning in childhood and continuing through adulthood, Grace secretly wore women’s clothes (at first, her mother’s and later, clothes she purchased). She felt overwhelming shame about this behavior and tried to stop it many times, but always found herself drawn back to it and the relief it brought her (she referred to these episodes as “binges and purges”). In her youth, she thought she might be gay (though she was mostly attracted to girls), a “pervert,” or that she maybe had schizophrenia. She pled with God, and even the devil, to change her body to match her gender identity.

Grace endured several stressful events throughout her youth, including her parents’ divorce, disapproval from a church she attended, being bullied at school, legal troubles, and an incident where she was assaulted by police officers. Meanwhile, Grace struggled with depression and substance abuse and ultimately dropped out of high school. She started focusing on making her band successful and moved from Naples to Gainesville, Florida, which had a thriving punk scene at the time (shout-out to my friend’s band from that era, FIYA).

kathsing

Le Tigre show that I went to in Gainesville, 2000

While the success of Against Me! brought adventures, fans, and recognition of Grace’s skills and talents, there were also conflicts among band members, record label issues, difficulties in her first marriage, and a backlash from some punk rock purists who thought Against Me! had sold out. She tried to distract herself from the gender dysphoria by channeling her attention into music, drugs, drinking, and working out. She tried repeatedly to accept living as a man and tried to push ideas of living as a woman out of her mind. Grace recalled a particular time on tour when she and her band saw a group of transgender women walking together. She joined in with her bandmates to make fun of them, while secretly wishing she was as brave as them. No one in her life was aware that she was going through these struggles, even though she wrote lyrics about her gender dysphoria in Against Me! songs. In 2007, Grace got married for the second time. The gender dysphoria decreased during certain periods of her marriage, but always returned (including during her wife’s pregnancy with their child, who was born in 2009).

Grace decided that she would come out as a transgender woman in a 2012 Rolling Stone article at the age of 31. After beginning her transition, she felt more authentic and experienced relief from her gender dysphoria. Still, she continued to face challenges. She got divorced and her father stopped talking to her after she disclosed that she was transgender. Through the hardships, Grace continued to speak out about the rights of transgender people, talk openly about mental health issues, make really good music, and inspire many people. That’s my brief summary of her book — but seriously, you should read her entire memoir, which concludes with this lovely moment between Grace and her daughter:

It’s the new issue of Rolling Stone. On the cover is a close-up shot of Madonna. She looks exactly the way I remember when I first saw her at five years old, the same age Evelyn is now. Red lipstick, piercing blue eyes, not a single hair out of place. Her skin is delicate and gorgeous.

“Daddy, who is this?” she asks me.

“That’s Madonna, Evelyn,” I tell her. She’s a musician.”

“Just like you?”

“Just like me.”

am.jpg

Against Me! playing in Lansing, Michigan in 2018

While I’ve been wanting to write this post since I first read the book, my motivation was renewed after the release of the “trans military ban” memo, which states that “transgender persons with a diagnosis or history of gender dysphoria…are disqualified from military service except under certain limited circumstances.”  The link between gender dysphoria and suicidality was cited as one of the reasons for this decision. Estimates vary across studies, and there are methodological components that should be carefully considered, but the existing research consistently finds an elevated risk for suicidal ideation, suicide attemptssuicide-related events, self-harm, and suicide among transgender and gender-nonconforming (TGNC) people. I will unpack some of what we know about this empirical relationship, but I want make it clear that I agree with the American Psychological Association and the American Medical Association that the memo is discriminatory. It’s worth reading both organizations’ statements in full here and here.

Back to Laura Jane Grace…in a 2017 interview, she referred to herself as “part of” the 41% lifetime suicide attempt rate among TGNC people. That statistic should be interpreted within the context of the methodology (the report acknowledged that the rate might be inflated due to measurement and sample recruitment methods). Data were not collected on the timing of the suicide attempts in relation to transitioning, which was another limitation of the study. Grace attempted suicide ~1.5 years after she began transitioning, and she partially attributed it to a serious, adverse reaction to the hormones she was taking. In a 2016 interview, she described having suicidal thoughts at various points throughout her life, “…while I’ve struggled with gender dysphoria for my whole life, I’ve also struggled with depression. Those aren’t necessarily linked.” In her memoir, she points to a family history of mental health problems that may have contributed to her mood struggles as well.

The American Foundation for Suicide Prevention and the Williams Institute identified the following risk factors for suicide attempts among TGNC people (from the Executive Summary, p.2):

exec summary.png

Another study found that twice as many transgender youth (34%) reported suicidal desire in the previous year as compared to non-transgender youth (19%) and that depression and school-based peer victimization explained part of the empirical relationship between gender identity and suicidal ideation. Here again, it’s important to interpret the findings within the context of the methods (in this case, self-report questionnaires with some limitations were used).

A 2017 study sought to build on existing research by testing a general theory of suicide (the interpersonal-psychological theory of suicidality, IPTS) and the gender minority stress and resilience model (GMSR) among TGNC adults (again, it’s important to look at the study details for full context when interpreting the results). They reported two main findings: 1) GMSR variables (e.g., discrimination, victimization, internalized transphobia, non-affirmation) explained 20% of the variance in suicidal ideation in the sample and 2) IPTS variables (i.e., social disconnection and perceiving oneself as a burden on others) mediated the relationship between GMSR variables (internalized transphobia, negative expectations for the future, and nondisclosure of one’s gender identity) and suicidal ideation, accounting for 54% of the statistical variance in the sample. A study in TGNC youth also found that IPTS variables were correlated to suicidal ideation and suicide attempts, while another found that a GMSR-related variable (being addressed by a chosen name in multiple contexts) was linked to lower depression and suicidality among TGNC youth.

In summary, we need more research to fully understand elevated suicidality risk among TGNC people. The available science suggests that depression, discrimination, victimization, and other structural factors (e.g., difficulty accessing medical care and affirmative mental health practice) disproportionately impact the TGNC community and contribute to suffering, as Grace wrote about in her memoir. For an equitable and just society, we must join with those working to break down these societal barriers. It’s the compassionate and right thing to do.

I’ll conclude with this wisdom from Laura Jane Grace:

Interviewer: Do you ever get tired of being part of people’s learning curve and constantly explaining to people?

Laura Jane Grace: I don’t get tired of it in a way…talking about trans issues, trying to educate people about trans issues — translates to a real world thing that does actually save lives and helps make other people’s lives easier, including my own. That’s what it’s about…humanizing things.

I wanted to keep this post relatively brief, but if you are interested in learning more about any of the ideas presented in it, you can check out some of these links:

Learn More about the Diverse Lived Experiences of TGNC People in Their Own Words: Aydian DowlingChaz Bono, ContraPoints, Jazz JenningsJanet MockLaverne Cox, Leelah Alcorn, Live Through This ProjectTrue Trans documentary series with Laura Jane Grace, Trans documentary

Information for Mental Health Professionals about Affirming Psychological Practice With TGNC People: APA Guidelines, A Model for Children & Adolescents

Suicide Prevention Resources: American Association of Suicidology, American Foundation for Suicide PreventionNational Suicide Prevention Lifeline, Trans Lifeline, The Trevor Project, Darcy Jeda Corbitt Foundation