Science Can Meaningfully Advance Public Discussion About Suicide

March 24, 2019March 25, 2019 / kgordonlab / 2 Comments

hope

Public discussion about suicide is dominated by particular types of narratives. Media outlets tend to focus on celebrities who, despite outward signs of success, are tragically driven to despair. Other news stories tell heartbreaking tales of young people who end their lives after experiencing readily identifiable stressors. This coverage is important, and compassionate media depiction is crucial for public understanding. However, discourse that’s constrained to certain kinds of stories obscures two key points: 1) suicide is really complicated and 2) it can affect anyone. With a trend of rising suicide rates in the United States, we need to expand our conversations and make more room for nuance.

Five years ago, I heard a story about a suicide attempt that broke the typical media mold. It was this powerful NPR Story Corps segment about a man named Kevin Berthia, who was extremely close to jumping off the Golden Gate Bridge. In under three minutes, listeners learn that Berthia suffered from depression throughout his life and that this escalated to suicidal thinking when he couldn’t pay for his infant daughter’s enormous medical bills. This triggered embarrassment, self-directed anger, and feelings of failure. Filled with urgency to escape his overwhelming pain, he got directions to the bridge and climbed over the railing. He was stopped by an empathetic police officer, Kevin Briggs, who spoke with him for an hour and a half on the ledge before he decided to climb back to safety. Berthia’s life was saved, but his struggles continued for years. In a piece for the Guardian, he wrote, “Reporters are always after the happily-ever-after ending.” This coverage stands out because it includes his backstory and the moment-to-moment details of Berthia’s path toward, and ultimately away, from suicide.

Suicide is the result of a culmination of factors pushing people into excruciating states where death is viewed as relief. Suicidologists acknowledge that diverse pathways lead to suicidal desire and seek to identify commonalities among people in acutely risky states. For example, Berthia had pre-existing vulnerabilities related to growing up with some family conflict and in a neighborhood where he was pressured to hide his depression. Then, compounding the uniquely jarring worry of having a child in compromised health, Berthia also blamed himself for not being able to foot medical bills to the tune of a quarter of a million dollars. This propelled him to the Golden Gate Bridge with the thought, “All I gotta do is lean back and everything is done. I’m free of all this pain.”

Between StoryCorps and the Guardian article, we get a sense of several contributing factors and potential intervention points that are generalizable beyond Berthia’s individual situation. For example, there seems to be a sustained cultural push against the belief that people should hide depression. And while the Affordable Care Act sought to partially address the dire state of affairs for many Americans facing medical costs, additional changes are desperately needed to overhaul a system that leaves people struggling to meet basic physical needs. A comprehensive suicide prevention initiative would address these and other empirically-linked risk factors (e.g., incarceration, homelessness, combat exposure, physical illness, mental illness, and discrimination). This long list of suicide risk factors can leave people feeling overwhelmed and unsure of how to help. Thankfully, Klonsky and May (2015) developed a scientific framework called the Three-Step Theory (3ST) that meaningfully organizes and prioritizes this information:

3ST diagram

from Klonsky, May, & Saffer, 2016

Berthia’s experience appears to fit within the 3ST. The first step proposes that people desire suicide in the presence of pain and hopelessness about the future, “If someone’s day-to-day experience of living is characterized by pain, this individual is essentially being punished for living, which may decrease the desire to live and, in turn, initiate thoughts about suicide” (pp. 116-117). Within the 3ST, suicidal desire could be reduced by targeting both distal factors (e.g., eliminating environmental factors that increase the probability of emotional pain) and proximal factors (e.g., increasing hope and coping skills). People advance to the second step of increased suicidal intensity if their pain overpowers meaningful connections to life. In the moment Berthia was about to jump to his death, Briggs emphasized Berthia’s connection to his daughter and the suicidal intensity decreased, “My daughter, her first birthday was the next month. And you made me see that if nothing else, I need to live for her.” A society seeking to prevent suicide would foster these kinds of connections, at multiple levels, for as many people as possible. The 3ST makes the case, building on the interpersonal theory of suicide, that the survival instinct prevents most people from attempting suicide even if they desire it. The third step usefully identifies three facets of a capacity to override this survival instinct: dispositional (e.g., genetics related to pain sensitivity), acquired (e.g., experiences that result in decreased pain sensitivity and lowered fear of death), and practical (described as knowledge of and access to lethal means – e.g., in Berthia’s case, getting the directions to the bridge and not facing a suicide barrier once there). The practical aspect of capability for suicide has been the focus of initiatives to reduce access to lethal means in times of suicidal crises (e.g., through safe gun storage). Increasing safety at times of suicidal crisis can have long-lasting positive effects, as most suicide attempt survivors do not go on to die by suicide.

Suicide is complicated and that contributes to widespread misunderstanding. Science can guide us away from investing resources in domains that have unknown relationships with suicide and toward those that have demonstrably stronger ones. Research illuminates potent risk factors and makes our understanding of suicide more precise. Suicide prevention advocates have increased public awareness about a variety of different suicidal experiences and continue to fight for public policy aimed toward saving lives. Recently, there have been excellent examples of compassionate, realistic media coverage and fictional depictions of suicidal behavior. Altogether, this suggests that the public has the will to prioritize suicide as a public health problem. Scientific frameworks like the 3ST can steer us in productive, solution-focused directions.

—

Suicide prevention information resources are available here, and here’s a summary of intervention research.

You can hear more of Kevin Berthia’s story here:

You can hear Kevin Briggs speak about Berthia’s story here.

The Cost of Giving the Benefit of the Doubt (or the Downside of an Elastic Heart)

March 21, 2019March 21, 2019 / kgordonlab / Leave a comment

warning: lots of speculation in this post and only a little science

heart

Something that preoccupies me these days is the puzzle of sharing psychological science in accessible, interesting ways without undermining its complexity. This is isn’t a new problem – many brilliant people have been working on it for a long time. There’s been substantial progress, even when it’s hard to compete with the attention paid to public-facing psychologists who sacrifice accuracy for various incentives (see Ali Mattu for an excellent example of someone not sacrificing accuracy for engagement). Still, there’s a core challenge that keeps running through my mind that’s not fixable through improving technology or reducing jargon or changing incentives. It’s that there’s rarely (ever?) a one-size-fits-all (or even-a-vast-majority-fits-all) situation in psychology due to variability between situations and people (which Sanjay Srivastava wonderfully captured when he deemed psychology the hardest science).

One way that people get therapeutic-like info out to the public is through the kernels-of-wisdom model (e.g., a tweet, a meme, or Instagram photo with a message like, remember that you’re trying as hard as you can and that’s good enough). This model is appealing because it’s low cost and could be just enough to brighten up someone’s day or spread some insight (by the way, check out Anna Ropp‘s awesome, scientifically-informed Psych Tidbits Instagram account). No one’s under the illusion that it would replace therapy or other bigger life factors related to one’s mental health, and it’s unlikely to harm anyone.

Then, there are more concerted efforts at advice-giving through videos, books, and social media with varying levels of credibility and scientific support. To oversimplify things, the advice is usually get yourself together or stop being so hard on yourself. So, herein lies my concern: I think people are bad at guessing which message applies to them. And while I don’t think a little-bit-of-wisdom type message here and there causes problems, I think there could be a negative cumulative effect of repeated messaging out in the world that people should take one of these two approaches to improve their lives. For example, I’ve seen people who could use the message about not being too hard on themselves absorb the one about getting themselves together and consequently pushing themselves even more to the brink. Meanwhile, there are people who could improve their lives by pushing themselves in certain ways but avoid that by telling themselves they’re just engaging in self-care. And I’m sure I’ve done both at times; it’s human nature to find justifications for the thing we already want to do.

I’m slowly funneling to a specific example, which is this: advice that is often given, including by psychologists, is to give people the benefit of the doubt. This appeals to me in a number of ways consistent with my values – it seems like a nicer, more hopeful, and less angry way to be. It’s consistent with the scientific framework of waiting to interpret something based on evidence instead of intuition. And it’s good advice if you’re the type of person who would otherwise lean toward hostile attributions. On the other hand, consistently giving people the benefit of the doubt has costs that I rarely see acknowledged:

-It means questioning yourself a lot more when you sense that someone intends harm, which can erode your ability to trust your own perceptions.

-Without a belief that you can accurately assess and interpret situations, you can get stuck in a state of inaction rather than moving to resolve an issue.

-It can mean ignoring ambiguous, but existent warning signs that would have removed you from a dysfunctional situation earlier.

-If you’re prone to self-doubt, it may lead you to feel foolish for assuming good will in the first place. This is taxing and can affect productivity even once you’re in a better subsequent situation.

-People often trust cynics more than recurrent benefit-of-doubt-givers, as though they’re closer to truth when they assert their opinions. Cynicism is more likely to (erroneously) signal critical or deep thinking than benefit-of-doubt giving, which is typically linked to being naive or a pushover.

-A nontrivial number of people won’t reciprocate. It’s a good thing to assume the best in people in and of itself sometimes, but it’s also useful to strategically employ it with the hope of improving communication. Unfortunately, there are people who will take advantage of your approach while not extending any charitable interpretations to your behavior.

Despite every single cost I mentioned, I’d still argue that benefit-of-the-doubt giving is worthwhile and generally good advice to follow (perhaps because it’s aligned with my values or simply to justify my own past and future behavior). But, I’ve been reflecting on the costs more recently and thought writing them out might lead to hearing other people’s perspectives — so, I’m eager to hear what others think about the specific example or the broader issue of communicating universal psychology messages (but only if you mean well).*

—

*I’ll assume you do.

Can Offensive Political Speech on Campus Cause Trauma?

March 11, 2019April 30, 2019 / kgordonlab / 2 Comments

I went on Half Hour of Heterodoxy to talk about student reactions to political extremists giving speeches on college campuses. I was grateful for Chris Martin‘s interesting questions and wanted to expand on a few of the discussion points.

What’s the definition of trauma?

The DSM-5 defines trauma as exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1) directly experiencing the traumatic event(s), 2) witnessing, in person, the event(s) or the event(s) as it occurred to others, 3) learning that the traumatic event(s) occurred to a close family member or close friend, 4) work-related repeated or extreme exposure to aversive details of traumatic event(s).

Do political extremists cause trauma when they speak on campus?

DSM-defined trauma is unlikely to occur at these events unless there’s actual or threatened violence involved (e.g., 1, 2, 3, 4). It’s important to avoid watering down the term trauma through misuse in situations where it doesn’t apply. However, I don’t think fear of acute trauma typically drives the opposition to political extremists on campus. I think the fear is more commonly about political extremists using campus appearances to spread discriminatory beliefs that perpetuate social inequities. The sense of threat comes from historical knowledge about the uses of propaganda, and it’s amplified when violent acts are carried out that reference this propaganda (e.g., 1, 2, 3, 4). Some political extremists explicitly state that they’re trying to recruit college students to their causes (1, 2) and have developed strategies for persuading people through coded language (e.g., 1, 2, 3). Despite trauma being an unlikely consequence of these speeches, there is a robust literature showing that experiences of discrimination are related to worse mental and physical health (e.g., 1, 2, 3)* and that people can have physiological stress responses when exposed to discrimination and racism.** For example, it’s been proposed that these types of stress responses contribute to birth outcome disparities between Black and White women in the United States (e.g., 1, 2).

What should universities do?

1) Actions should be individually-tailored for the particular university and involve discussion with students and faculty, instead of something pushed top-down from administrators. Include mental health experts in these conversations.

2) Express support for faculty and students. Even if you disagree with their viewpoints, don’t ridicule students or erroneously reduce all of their concerns to an inability to handle differences of opinion. Students are exposed to politically extreme views in spaces outside of campus speeches, and that exposure often shapes their beliefs about the particular speaker and the potential for harmful societal consequences. It’s not helpful to deride students who respond by using their time and resources to organize nonviolent protests to combat social inequality.

3) Don’t equate mental health issues with weakness or confuse therapy with avoidance. Normalize discussions about mental health on campus. University-wide e-mails are sent around about flu shots and other medical issues – it can be helpful to do the same with mental health information and resources. When people seek counseling, the first step involves determining whether the person has a mental health problem. If a student refers to something as trauma when it’s not, therapists provide them with that valuable corrective feedback. There’s also a misconception that therapy is about unconditional reassurance or hand-holding, but it’s actually all about empowering people to face their problems skillfully.

4) Be precise in stating your rationale for hosting speakers on campus. I doubt that many university administrators think there is educational value in speeches by people like Richard Spencer. Usually, they’re motivated by the importance of upholding free speech principles and are legally obliged to host speakers in public spaces. I’ve heard some arguments that there are educational and mental health benefits to having political extremists on campus (e.g., via exposure to “new and challenging” ideas). The free speech argument is compelling, but the educational and psychological growth arguments are not. I’m not aware of any evidence that exposure to inaccurate, dehumanizing ideas about groups of people confers psychological benefits (if you are aware of such research, please share it with me). For example, some students have opposed Ben Shapiro speaking on their campuses. As I have written about, he spreads false information about suicide and trans people (also watch Natalie Wynn refute Shapiro’s claims). It’s hard to comprehend how learning inaccurate ideas, which are used to restrict rights (e.g., 1, 2), add value to students’ lives. When someone argues that accuracy and education don’t matter when it comes to protecting free speech, I find that much more convincing and honest.

A recent video by Natalie Wynn included a nuanced description of her response to Ricky Gervais telling transphobic jokes in his comedy specials. She made it clear that the thing that bothered her wasn’t that he’s allowed to tell those jokes (she’s a huge proponent of free speech) or even that the jokes are unoriginal, unfunny, or offensive. Rather, she’s afraid that he’s spreading untruthful ideas that make the world a harder place for people like her (she’s a trans woman). Her descriptions reflect the kind of complexity and clarity needed for productive conversations about the psychological effects of these types of speech.

*This paper describes the complexities of measuring discrimination in research.

**Individual differences between people and situations determine the extent to which any particular person will be affected by an event.

Information & Resources

Accurate information about trauma and posttraumatic stress disorder is available here.

For student organizer perspectives, listen to Hoai An Pham here (episode 10) and read Maximillian Alvarez’s article here.

Chris Martin‘s Half Hour of Heterodoxy podcast has featured guests with a variety of opinions on free speech and other campus-related issues.

Two particularly thoughtful academics who write about campus free speech issues are Aaron Hanlon and Jeffrey Sachs.

I’ve learned a lot about First Amendment litigation from reading work by Ken White and FIRE.

I co-wrote a blog post on college mental health that you can access here.

Acknowledgments

In preparation for the podcast, I reached out to three people with relevant expertise and experience: Dr. Yessenia Castro, Linda Gordon, and Carly Marten. They generously shared research, articles, resources, and their thoughts with me. I’m thankful for how much they deepen my understanding of these issues and for all that they do to make the world a better place.

A Short Guide to Everything You Need to Know About Eating Disorders

February 28, 2019February 28, 2019 / kgordonlab / 4 Comments

nedawareness_week_2019-shareables1

In honor of National Eating Disorders Awareness Week, I will attempt to create a post that links to everything you need to know about eating disorders.*, **

*Or at least gets you within a couple of clicks of a lot of things that are good to know.

**Scientists and clinicians don’t actually know everything we need to know about eating disorders yet, but I’ll share what we do.

Definitions

The Diagnostic and Statistical Manual of Mental Disorders includes formal definitions of eating disorders, such as anorexia nervosa, bulimia nervosa, binge eating disorder, and others. Even if someone does not meet full diagnostic criteria for an eating disorder, they may still struggle with eating disorder symptoms such as body dissatisfaction, loss-of-control overeating or undereating, preoccupation with food, weight, or shape, or unhealthy weight loss behaviors (e.g., abusing laxatives, self-induced vomiting, compulsive exercise). If you’re curious about your own eating behavior, you can take an online screening here.

Causes

There are a variety of different factors that increase the risk for eating disorder symptoms. You can read about them here or see the biopsychosocial model below for some of the main factors associated with eating disorders.

Treatments

Current research-supported eating disorder treatments include: family-based or Maudsley treatment, cognitive-behavioral therapy, integrative cognitive-affective therapy, and interpersonal psychotherapy.

There are also some scientifically-informed self-help books available:

Help Your Teenager Beat an Eating Disorder

Overcoming Binge Eating

The Body Image Workbook

Additional Eating Disorder-Related Topics

Activism

Emotion Regulation

How to Help A Loved One

The Marginalized Voices Project

More Eating Disorder Resources

Association for Behavioral and Cognitive Therapies

Academy for Eating Disorders

National Eating Disorders Association

Podcast Episodes on Eating Disorders (1, 2, 3)

How Psychologists Capture the Complexities of Mental Illness

February 11, 2019February 12, 2019 / kgordonlab / 6 Comments

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.

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 maltreatment, increase 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:For 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.

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.

Suicide is Not Reducible to Simple Explanations

February 6, 2019February 7, 2019 / kgordonlab / 1 Comment

It is unlikely that any one theory can explain phenomena as varied and complicated as human self-destructive acts. At the least, suicide involves an individual’s tortured and tunneled logic in a state of intolerable, inner-felt, idiosyncratically-defined anguish.

-Edwin Shneidman, founder of contemporary suicidology

When criticizing aspects of society, some people amplify their arguments by saying that those aspects cause suicide. Typically, the claim goes something like this, “____ is so bad that it leads people to kill themselves. Therefore, it’s urgent that we stop ____.” You should be skeptical when you hear these kinds of claims, because suicide is not reducible to simple explanations. It hurts to think about people grieving a suicide loss and then hearing that there was a simple fix all along. This is especially painful when there is little or no evidence that ____ substantially increases suicide risk. Additionally, if an empirically-weak claim receives enough public attention, limited suicide prevention resources can be squandered in the wrong places.

How to Evaluate Causal Claims about Suicide

Suicide is complex, and it’s extremely challenging to conduct research that yields results with causal implications. The closest we have to experiments may be randomized controlled trials designed to reduce suicidality. Keeping in mind that the majority of suicide research is correlational, here’s one set of criteria that you can use to evaluate whether ____ causes suicide.

1) temporal precedence: If ____ causes suicide, ____ must occur before the suicide (or a societal change must precede changes in suicide rates). Non-experimental research can speak to this criterion through longitudinal studies or other examinations of suicide rate data over time. However, it’s important to look at long-term trends rather than capitalizing on specific time points with fluctuations that are consistent with the claim.

2) covariation: If ____ causes suicide, then changes in ____ must accompany changes in suicide rates. I often see partial demonstrations where someone will say, “Here are higher suicide rates coinciding with more of ____,” but then leave out the necessary counterpart of establishing correlation: less of ____ should also be associated with lower suicide rates. Both are required to meet this criterion, and you don’t need experimental studies if you examine it through naturally-occurring differences. For example:

-Looking at World Health Organization suicide data, do countries with more of ____ have higher suicide rates than countries with less of ____?

-Do demographic groups who experience more of ____ have higher suicide rates than groups with less of ____ over the same time period?

If the answer is “no,” then the covariation criterion has not been met.

3) nonspuriousness: If ____ causes suicide, then the relationship must persist even after ruling out alternative explanations. This criterion is arguably the most difficult to prove without experimental studies, but there are some correlational data that you’d expect to see if the claim is true. Questions to ask of such claims include:

-What else increased aside from ____ during the time period of increased suicide rates? Is there research linking those other factors to suicide, and could that better explain the observed pattern?

-Do people experiencing more of ____ also experience more of something else empirically-linked to suicide that could better explain the observed pattern?

Here‘s a strong example of someone evaluating an alternative explanation for an observed pattern using correlational data on a completely different topic (specifically, the part on self-censorship).

I wrote this post to share a framework for evaluating causal claims that I learned in grad school, and I hope that you find it useful. Even if it’s completely unintentional, when people use unsubstantiated claims about suicide to magnify societal concerns, it can feel exploitative of a group of people I care deeply about. Fortunately, this is outweighed by incredible, compassionate work reflecting the complexities and multiple pathways to suicide. I’ll link to some of my favorites below:

American Association of Suicidology

The Best Way to Save People from Suicide

The Interpersonal Theory of Suicide

Live Through This

Suicide Prevention Social Media Chat

The Three-Step Theory

We Tell Suicidal People to ‘Get Help.’ But What Happens When They Do?

Thank you for reading! Here’s a post with more information and resources about preventing suicide.

rainbow

In Defense of Diagnosis

February 5, 2019February 5, 2019 / kgordonlab / 2 Comments

In “Why I Do Not Attend Case Conferences,” Paul Meehl (1973) described reasoning errors that emerge during case conceptualization conversations among mental health professionals. One of the issues Meehl discussed at length (pp. 272-281) was an antinosological bias, defined as “an animus against diagnosis.” Here’s his response to a common objection to diagnostic labels:

passage

Meehl described his style there as “highly critical and aggressively polemic,” which he justified by saying, “If you want to shake people up, you have to raise a little hell.” The second section has a much more constructive tone. Both sections are valuable, and I agree with his overall thesis that compassionate, effective mental health care requires clearheaded case conceptualization. Meehl is also correct that 1) meaningful diagnostic systems are crucial for advancing the field and 2) some critiques of the Diagnostic and Statistical Manual of Mental Disorders (DSM) reflect misunderstandings of the diagnostic process. I’ll discuss some of the major criticisms and benefits below.

Criticisms

1. The DSM pathologizes nonpathological behavior.

Barbara_Gittings,_Frank_Kameny,_and_John_Fryer_in_disguise_as__Dr._H._Anonymous_

Barbara Gittings, Frank Kameny, & Dr. H. Anonymous, gay rights activists at a 1972 APA convention

This is true in specific cases. One of the most well-known examples is homosexuality being labeled as a mental disorder in older versions of the DSM. As a result of persistent, organized activism bolstered by research, homosexuality was removed from the DSM. You can learn more about it in excellent podcast episodes by This American Life and Radiolab. Currently, the DSM developers attribute elevated mental health problems among lesbian, gay, and bisexual people to discrimination, actively oppose conversion therapy, and push for policies and law that reduce disparities. In order to prevent future harm, this history must be considered in diagnostic decisions. As Martin Luther King, Jr. said, psychology shouldn’t label people as maladjusted for not adjusting to bigotry.

However, we should also consider that appropriate diagnoses have helped people access beneficial services (e.g., children with intellectual disabilities or autism receiving accommodations in school and other public places). Additionally, the DSM specifically instructs clinicians to only assign diagnoses when a cluster of multiple symptoms: 1) causes clinically significant distress and/or impairment, 2) is persistent and severe for a length of time, 3) deviates significantly from developmental expectations, and 4) cannot be attributed to other factors (e.g., medical, cultural). These types of safeguards reduce the likelihood of pathologizing nonpathological behavior.

2. People are over/misdiagnosed.

Misdiagnosis occurs for many reasons ranging from improper assessment procedures, failure to consider pertinent contextual factors, and biases. For example, attention-deficit/hyperactivity disorder is a meaningful diagnostic category with real-world implications. Nonetheless, there’s evidence that it may be overdiagnosed, which can lead to inappropriate treatment plans.

Issues that exacerbate the problem include 1) lack of funds/insurance coverage for comprehensive assessment procedures and 2) diagnosers who rely too much on their intuition instead of established diagnostic tools. The Ethical Principles of Psychologists and Code of Conduct lays out stringent rules for assessment. A system that ensures adherence to these rules would reduce misdiagnosis while permitting proper diagnosis for people who need treatment and/or services.

use of assessments

3. Classification decisions are made by people with conflicts of interest.

There have been some egregious examples of psychiatry researchers receiving large sums of money from pharmaceutical companies and not properly disclosing them. One instance is covered in a PBS Documentary and in this New York Times article:

grassley

In an effort to address this problem, DSM-5 panel members were required to disclose conflicts of interests. Cosgrove and Krimsky (2012) made a compelling case that further action was needed:

COI

To be clear, psychiatric medications have helped numerous people and are warranted in particular circumstances. However, steps must be taken to reduce potential biases driven by the pharmaceutical industry.

4. Labeling someone with a mental disorder is stigmatizing.

Despite signs of improvement, prejudice and stigma continue, especially for certain mental health conditions. The solution is to eradicate the stigma rather than the nosology (but it’s worth listening to Szasz’s arguments opposing that idea). When properly applied and understood, diagnoses can alleviate suffering by pointing to effective treatments, connecting people with support and advocacy groups, and evoking compassion. This was nicely demonstrated in Crazy Ex-Girlfriend:

I’m aware mental illness is stigmatized/But the stigma is worth it if I’ve realized/Who I’m meant to be/Armed with my diagnosis

5. Diagnostic categories do not accurately reflect nature.

There are different versions of this, but I’ll focus on the most common: 1) most mental health problems are dimensional (occurring on a continuum) rather than categorical (e.g., there are gophers and chipmunks, but no “gophmunks“), 2) there’s too much variability within diagnostic categories for them to be meaningful, and 3) DSM symptoms are not necessarily the core symptoms of disorders (e.g., for depression).

cute-chipmunk-wallpaper-24729-25401-hd-wallpapers

In response, 1) people have proposed replacing the categorical model with empirically-informed dimensional models (e.g., even if psychopathy occurs on a continuum, it’s quite meaningful to diagnose those in the highest range), 2) diagnostic presentation variability depends on the diagnosis (e.g., people with bulimia nervosa have more in common, on average, than people with borderline personality disorder) and fewer diagnoses with more specifiers could help (e.g., see Pincus, 2011), 3) network analyses are useful for identifying the central symptoms of mental disorders. A concern about major DSM changes is that they will disrupt the work of clinicians and researchers (see Pilkonis et al., 2012). Despite these issues, we need to create a DSM that’s better at carving nature at its joints rather than resisting change or giving up the enterprise altogether.

Benefits

1. Agreed upon definitions facilitate clinically-relevant research.

I agree with McFall’s Manifesto (1991), which states that “the future of clinical psychology hinges on our ability to integrate science and practice” (to hear this debated, check out this Talk of the Nation episode). For example, treatment research for bipolar disorder has more generalizability to real-world clinical settings when therapists and scientists use the same operational definition of bipolar disorder. Moreover, consistent mental disorder definitions across studies makes cumulative knowledge possible. Classification systems enhance communication and research, which contribute to the big picture goal: alleviating suffering.

2. Diagnoses convey useful information when derived from appropriate assessment procedures.

Accurate diagnoses point to literature on the causes, correlates, and effective treatments for specific mental health problems. If an adolescent girl is accurately diagnosed with anorexia nervosa, we learn that she has an increased risk for bone fractures, arrythmias, depression, and suicide and should be monitored for each of these dangers. Importantly, we also know that family-based treatment is likely to be a good treatment option for her and that her parents can connect with parents experiencing similar struggle s. To learn more about the process for evaluating levels of empirical support for therapies, look here for youth treatments and here for adult treatments.

3. Diagnostic feedback (when done well) can lead to positive effects.

People tend to experience positive feelings (e.g., optimism, relief) after receiving diagnostic information derived from appropriate assessment procedures and delivered in a collaborative, constructive manner. Similarly, there’s evidence that taking personality inventories and being told about the results from a therapist leads to increased self-esteem, more perceived self-competence, and lowered distress. Why would people feel better after learning about their mental health problems and potentially maladaptive personality characteristics? My guess is that people already know that they’re experiencing certain kinds of issues. When a therapist demonstrates an understanding of the problems by placing them in a meaningful context, they feel validated and hopeful that they can be helped.

4. Diagnostic labels enhance communication between treatment team members and aid continuity in care.

Diagnostic labels ease the transition for clients from one therapist to another (e.g., by saving them from having to repeat assessment procedures) and by communicating efficiently to other members of their treatment team (e.g., social workers, psychiatrists, physicians, clergy).

5. The DSM-5 has improved since the original version and has built-in mechanisms for change.

Despite the hindrances mentioned above, the DSM has formal, built-in processes for evolving with new scientific discovery. New versions are created with the explicit goal of making the classification system better reflect nature. Hyman (2010) argued that we should not reify existing diagnostic constructs. Instead, we must remember that diagnoses are constructed for clinical and scientific purposes. Therefore, improving the DSM requires openness to change and flexibility.

In conclusion, despite the concerns highlighted above, I agree with Meehl that antinosological biases impede progress and that mental health classification systems should be improved rather than abandoned altogether. I’m grateful for the dedicated clinicians and scientists working to deepen our understanding of mental health and feel encouraged by efforts to use that information to improve people’s lives.

—————————————————————————————————————————————–

In an effort to keep this post relatively brief, I highlighted some main points and examples. Some of the more technical, in-depth things I’ve co-written about classification are linked below:

The Classification of Eating Disorders – The Oxford Handbook of Eating Disorders

Empirical Approaches to the Classification of Eating Disorders – Developing an Evidence-Based Classification of Eating Disorders

Nonsuicidal Self-Injury Disorder: A Preliminary Study – Personality Disorders: Theory, Research, and Treatment

Patients’ Affective Reactions to Receiving Diagnostic Feedback – Journal of Social & Clinical Psychology

Suicidal Behavior on Axis VI – Crisis

Taxometric Analysis: Introduction and Overview – International Journal of Eating Disorders

The Validity and Clinical Utility of Binge Eating Disorder – International Journal of Eating Disorders

—————————————————————————————————————————————–

A major inspiration for creating the Jedi Counsel blog and podcast was to demystify issues surrounding diagnosis through analyses of fictional characters.

3000x3000_JediCounsel

Things I Liked In 2018

December 20, 2018February 28, 2019 / kgordonlab / Leave a comment

There was so much going on in 2018 that I leaned on journalism, podcasts, and art more than usual to challenge, clarify, and enrich my understanding (and for comic relief too). I listed the most memorable of those things below, and I’d love to hear about your favorite things to read, listen to, and watch this year in the comments or on Twitter.

To read

Amber Wyatt Told Her Story Of Rape. This Is How The World Responded. by Elizabeth Bruenig

The Best Way To Save People From Suicide by Jason Cherkis

My Own Devices by Dessa

Finding David Sedaris by Katie Herzog

Everything You Know About Obesity Is Wrong by Michael Hobbes

Here’s How Cornell Scientist Brian Wansink Turned Shoddy Data Into Viral Studies About How We Eat by Stephanie Lee

Protest Isn’t Civil by Vann Newkirk II

100 Million Americans Have Chronic Pain. Very Few Use One Of The Best Tools To Treat It by Brian Resnick

There Is Only One Trump Scandal by Adam Serwer

When Children Say They’re Trans by Jesse Singal

When The Muzzle Comes Off by Rebecca Traister

To listen to

1A: The Persistence of Segregated Schools

The Black Goat: The Year 2018 In Review

Circle Of Willis: Children At The Border

Everything Hertz: Shit Academics Say With Nathan Hall

Laura Jane Grace & The Devouring Mothers: Bought To Rot

Unerased: Dr. Davison And The Gay Cure

A Star Is Born Soundtrack

Tatter: Mission Creep (On Carrying Implicit Bias Too Far)

Two Psychologists, Four Beers: The Replication Crisis Gets Personal

To watch

Bad Times At The El Royale (and the soundtrack is fantastic too!)

Culturally Determined: Life With Depression

NPR Music Tiny Desk Concert: Wu-Tang Clan

Queer Eye

Wynonna Earp

10-Year Post-Ph.D. Post

September 17, 2018November 19, 2018 / kgordonlab / 1 Comment

633552940369053406 hoodingmyk

left: my graduate mentor hooding me; middle & right: hooding my first two Ph.D. students

I graduated with a Ph.D. in Clinical Psychology 10 years ago! I thought I’d reflect on that by responding to a tweet by Nathan C. Hall (check out the full thread of responses to his tweet here, an article on it here, and discussion of it on a podcast here.

nch

1. Don’t despair when you’ve invested a lot of time in a study and the results are not statistically significant. There’s a future process coming that will allow you to publish these studies as long as they’re rigorous (Registered Reports).

2. Even though mentoring graduate students provokes a lot of uncertain/anxious feelings, it will end up being one of the most meaningful aspects of your job.

3. You overestimate how much your treatment of people influences how they treat you. People’s goals, personalities, motivations, and other incentives guide their behavior too (more so than yours in some cases).

4. When deciding what to teach within time constraints, prioritize depth over breadth and make time to teach students about process (e.g., how to find and critically evaluate the research on depression treatment) over content (e.g., reviewing every type of depression treatment currently used).

5. Don’t neglect the importance of sociocultural factors in biopsychosocial models of psychopathology. I didn’t even realize I was almost exclusively focused on biological/psychological factors in my abnormal psychology class until a student commented on it in my evaluations during my first year of teaching. I’m really grateful they did that. It made my subsequent teaching more comprehensive.

NDSU

6. Demonstrate the importance of course subject matter by taking time to discuss it within its historical context and current real-world significance (e.g., on intelligence – 1, 2, 3, 4, 5).

7. Even though you think you’ll regret it later, you’ll actually be grateful that you turned down some work opportunities when you were already overloaded with work.

8. If you’re experiencing burnout, try looking at your situation through an operant conditioning lens. Identifying reinforcements, punishments, etc. in your situation can produce problem-solving ideas. This was advice I got from someone else that stuck with me.

9. There are certain types of work in academia that are more frequently and formally recognized and rewarded than others. That doesn’t mean that the other work isn’t of value. Reminding yourself of that with regard to your own and others’ work is important.

10. I don’t know how to phrase this last one except to say that I am extremely grateful for all of the trusted friends and colleagues I have been able to consult when I am unsure of something ranging from scientific to interpersonal aspects of academia. In advice form: don’t hesitate to ask for help from people you trust. And pay it forward when you’re the one who is asked.

Suicide Prevention Information & Resources

June 9, 2018January 25, 2019 / kgordonlab / 6 Comments

This week involved a lot of heartbreaking suicide-related news. We tragically lost Kate Spade and Anthony Bourdain to suicide. We also learned that U.S. suicide rates increased substantially over the past several years. If you want to learn and do more to prevent suicide, I want to help you out by linking to some good sources. I hope you find them useful.