Category Archives: Ethics

The Map and the Territory

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The other day, a colleague of mine called me to consult on a case.   The client was a young adult who had been diagnosed with autism.   At one point she said, “His black and white thinking is caused by his autism…” My heart rate instantly quickened and before the apoplexy could do too much brain damage I interrupted her and curtly said, “No. His black and white thinking isn’t caused by his autism, his black and white thinking causes his autism.” She seemed confused, so I did my best to explain the damage that can be done by reifying labels.   I probably did a lousy job, because her mystification lingered.   I don’t know if I can do it better now, but I have the advantage of being able to cut and paste, so here we go.

I told my colleague that the more you rely on a label (a diagnosis) the less you are likely to know your client. Although it’s helpful, indeed necessary, when starting out in any field to learn the jargon, and thus have a convenient shorthand for describing a phenomenon and reducing the morass of information into manageable wholes, it can also lead us down wrong paths.   It is no accident that the more experienced a clinician the less jargon you will hear.

Humans are simply far more different from each other than we are alike.   The self-proclaimed “autistic” psychology professor Stephen Shore is credited with the cute saying that “If you’ve met one person with autism, you’ve met one person with autism.”

Diagnostic labels obfuscate more than they clarify.   Reducing someone’s personality to a group of symptoms does serve to focus on what some have concluded are the most meaningful bits and pieces, but by doing so we too easily fail to see the richness and contradictions of those behaviors that lie outside what we expect to see, and that makes us prone to errors.   If the label we give to the jar with the white powder in it is “flour” then that is what we expect will be in the jar, not the sugar that you put in the wrong jar when you were preoccupied with getting the internet upgraded. It is not necessarily that it becomes a self-fulfilling prophecy (although it could, if a therapist subtly steers his or her client toward the expected set of symptoms through explanations or interpretations that elicit those symptoms), but rather that the therapist actually “misses” the deeper truths of who is sitting opposite.

Diagnoses are, essentially, metaphors, in the same way Susan Sontag brilliantly described cancer as a metaphor in her seminal essay “Illness as Metaphor.”   Metaphors can be compelling ways to describe things, but they are not the same as the things we are describing. You can’t meaningfully say that John is schizophrenic any more than you can put a blanket of air on your bed, shoot an idea, buy a moral compass from the nautical supply shop, or really give me a piece of your mind.   That is not to say that—like John the Baptist, I cannot be a good shepherd even though I have no sheep. What I do mean to say is that I may indeed be a good shepherd, but I am much more than that, and by the way, I have goats (well, I used to). As the semanticist Alfred Korzybski famously said, “The map is not the territory.”

Another Hungarian hero of mine– Thomas Szasz, made a career out of professing that psychiatric diagnoses were essentially a form of social manipulation.   A psychiatrist himself, Szasz insisted that he was not anti-psychiatry, but anti-coercive psychiatry.   He saw psychiatric diagnoses as socially constructed with little to no medical evidence to support them, to be used, perhaps, to remove someone’s freedom (as in the case of hospitalizing a schizophrenic), cast someone aside from society (such as calling homosexuality a disease, which although eventually abandoned was done for decades), or sell drugs that don’t work or cause more harm than good.

Too many wrong roads are driven when we begin to think that the metaphor is the real thing.   The depth of personhood, the miraculous complexity and uniqueness of each individual, is transmogrified into the label we put on the package.   Korsybski once dramatically demonstrated this when he took a break from a lecture to eat some biscuits that had been wrapped in white paper. After commenting how much he enjoyed them, he offered some to students in the front row, who enjoyed their taste until Korsybski removed the white paper to reveal that they were dog biscuits. The students became nauseated, and Korsybski said something to the effect that we not only eat food, but we also eat words.

The problem with my colleague stating that her client’s “black and white thinking was caused by his autism” is that “autism,” as are most psychiatric diagnoses, is merely the label on the dog biscuit package.   It may or may not have anything to do with what is inside the package, but instead may have everything to do with what we think is in the package.   The truth is that, to this day, as is so with many things, we scientists know a lot about what the collection of symptoms we call autism looks like, but we don’t know much at all about how it comes about, or what goes on physiologically to cause those symptoms.

When we reify something, we also give it a static quality. We take something that should be a verb and turn it into a noun that just sits around on a shelf waiting for someone to pull it off.   And in doing so, we begin to think that there is little we can do with it.   If we only referred to John as a noun, as proper as that would be, we would imagine him standing somewhere.   But if we said he was “Johnning,” we would imagine all that he does that makes him tick.   Saying someone has autism, or depression, or even a virus, leaves us little to do with it, freeze-drying it as it were, and even creates a bit more distance between us and them.   If autism, or any diagnosis, was a verb rather than a noun we would be more interested in what it does and how it works, thereby bringing it to life and moving us to engage with it.

Another problem with my well-intended colleague’s comment is the direction of causality.   We need to know the territory before we can draw a map, but drawing the map will not create the territory.   We could say with some certainty that the more it rains the more umbrellas will be sold, but no matter how many umbrellas we buy we can’t make it rain. Does giving someone the label of autism make that person lose the ability to perceive life’s grays, or does the inability to perceive gray cause us to give someone the label of autism?   And if, as I would insist, it is the latter, then what useful information does that give us?   And if we make the mistake of reversing causality, thinking that this thing we call autism causes black and white thinking, it could freeze us in our tracks. We would have succeeded only in thinking we know something that we don’t, becoming autistic-like in our thinking and missing the grays, the subtleties that might lead us down different and potentially fruitful paths.

My colleague fell into a dangerous trap, but although the landscape of our language and everyday thinking is littered with those traps, no experienced clinician or practitioner of life should fall into them.   Confusing the map with the territory is something that ultimately can hurt our clients when the label is a psychiatric diagnosis, and when the labels we serve up are liberals, conservatives, Palestinians, Moslems, Jews, Christians, or maybe even Hungarians, we may succeed only in creating obstacles to understanding each other.

 

 

Mass Murder in the Alps

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The Germanwings disaster intrigues me more than most, perhaps because as a psychologist who flies for fun my interests bridge psychology and aviation, and all roads seem to be pointing to the mental health of the copilot who apparently flew the Airbus into the ground, killing himself and 150 others.

Crash investigators are charged with determining the cause of airplane accidents.   Cause is a complex, multi-layered concept.  One can say, for example, that the immediate cause of the Germanwings disaster was the co-pilot’s directing the airplane into a fast descent into the terrain below, causing the airplane and its inhabitants to break into pieces.   But what “caused” the copilot to direct the autopilot to fly the aircraft into the ground?

The word that I hear most often is “suicide,” one of those verbs that disguises itself as a noun.   Because we know that the copilot went onto the internet and looked up ways to kill himself as opposed to ways to commit mass murder we assume his intention was the former, and the others who died were “merely” collateral damage. But does calling the pilot’s action suicide get any deeper at the cause?

Psychologists have come a long way in understanding the ingredients of suicidal behavior.   But it is more difficult to imagine the depth of cognitive distortion, the outrageous amount of blindness that must occur when severely depressed to not feel for the families of others on board.

I have survived the suicide of four of my patients in my career, and scores more who either tried and failed or had strong enough impulses to require hospitalization.   In the vast majority of those situations, the perpetrator and the victim were the same.

I did have one suicidal patient who dealt with his anger toward his father (who had shot him at point blank range when my patient was a teenager) by “putting people in the hospital,” as he used to say.  Occasionally, he targeted police officers for his aggressive attacks, which were certainly suicidal gestures, but each time it occurred the police responded professionally and subdued him.   (On one occasion, two Burbank police officers brought him to my office instead of jail after he attacked a co-worker because they were either insightful or well-trained enough to realize that his aggression was a sign of his suicidality.)

What I don’t understand is the overwhelming number of press reports that refer to the behavior of the copilot as suicide instead of homicide.  One could argue, perhaps not too cleverly, that the copilot’s actions leading to the death of 150 people and his own makes it 150 times more likely to fall under the category of homicide than suicide.

I consider it a character flaw whenever I have difficulty finding compassion for the perpetrator of heinous acts.  Compassion for victims is easy; it is the perpetrators who need it more.  Understanding is helpful in finding compassion, but I don’t know that science will be able to determine the “reasons” why this copilot pointed his airplane’s nose to the ground.   There is no brain left to scan that might reveal a lesion.   We are left only with our theories, our knowledge that depression is often a combination of helplessness, hopelessness, distorted thinking, rage and blame turned inward.

This would not be the first time in history one has used an airplane as a weapon of mass murder.   But most of the others have been in the context of war between nations.   When mass murder takes place in the context of war within one’s own mind, there is no societal sanction to welcome you home.  The punishment of having ended one’s own life in the process does not bring the innocent victims back to life, nor does it lead very far down the road to compassion.

Perhaps more than most I should be able to understand someone whose depression is so great that he is able to transform his own pain into what can and arguably should only be called a case of mass murder-suicide.  But for me that is likely going to require considerably more effort.

Istanbul and the Armenian Genocide

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imagesAlthough the Armenian genocide at the hand of Ottoman Turks occurred almost exactly 100 years ago, I have avoided coming to Turkey partly because of feelings similar to those I had when first traveling through Germany in 1975.  Back then, as I felt the gentle swaying of the train and watched the beautiful German landscape slip past me, I couldn’t help but imagine myself being shipped off to a camp to be gassed, my lifeless body then piled in a mound with so many others who shared my fate.  Even though that occurred 30 years after the holocaust ended, as a 21-year-old I couldn’t help but feel the fear that echoed inside me through the generations.  Now, in Turkey, remembering stories of the murder of more than a million Armenians as the world looked away, I know the feelings that I share with my Armenian comrades are irrational; it is not as though the Turks living here today had anything to do with the behavior of their progenitors nearly a century ago.

In the book of Exodus we are told that the sins of the fathers will be visited on the children and the children’s children, to the third and the fourth generation.  Somewhat mysteriously, future generations bear the weight of their ancestors’ sins.   But that is certainly not to say they are responsible for their sins, as Ezekial clarified:  The son shall not suffer for the iniquity of the father, nor the father suffer for the iniquity of the son.  The righteousness of the righteous shall be upon himself, and the wickedness of the wicked shall be upon himself.

For many, apologizing for the behavior of ancestors seems altogether silly.  But for others, it is an essential part of a healing process.  In spite of the flak he received for it, when Bill Clinton apologized for American slavery, some healing occurred.   When Tony Blair apologized for the Irish famine, when the Pope repented for the behavior of the Catholic Church during the holocaust, when the Japanese prime minister apologized for the Second World War, some healing occurred.

Years ago, when teaching a family therapy course at Antioch, I discussed the Armenian genocide in class.   Afterward, a student came up to me and mentioned to me that she was Turkish.   In fact, her father was a Turkish ambassador.  She told me that I should be aware that there is also a Turkish side to the story.  Ever since, I have honestly struggled to learn the Turkish side of the story, just as I have struggled to understand the roots of the anti-Semitism that led to the Holocaust.  There may be explanations, but I really don’t know that there ever can be an “other side” to genocide.

Healing occurs because genuine apologies make the world a safer place.  Safety comes when we know ourselves and take responsibility for the harm that we are capable of perpetrating.  Or, in the words of the great philosopher Charles Shulz, “We have met the enemy, and he is us.”

Now, sitting on the terrace of my hotel room, overlooking the Bosporus on a warm, sunny spring morning in Istanbul, I think about the kindness, generosity, and sweetness of the four new Turkish friends who chose to spend their hard-earned day off with us yesterday.  One of them proclaimed in a discussion about the enmity that resulted after 9/11 and the subsequent backlash that “terrorism has no religion.”

In six days from now elections will be held that will likely keep Turkey’s president in power.   It is unlikely that this government will reverse its policy of selective memory and move toward truth or reconciliation.  That is sad, but eternal optimist that I am, I can only hope that over time governments will come to better represent the kindness and compassion of the people they govern.

 –written in April 2014 while in Istanbul on my way to Armenia

 

 

 

If You Can’t Get to Heaven: Leo Sandron and Ward 407

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images-2The food that was served to the staff in the cafeteria at Metropolitan State Hospital in Norwalk was just as bad as the food served to the patients.   That’s why many staff members walked across the street to the cafeteria at the modern headquarters of Bechtel, where we could sit and dine among the white shirts and ties of the engineers who were designing nuclear reactors and cities in Saudi Arabia.

I was sitting at a table with my supervisor, Leo Sandron, when a loud, corpulent psychiatrist walked over to us.   After Leo introduced me as his psychology intern, the psychiatrist remarked, “Oh, so you’re on ward 407.   You know what they say?  If you can’t get to heaven, go to 407!”

Attempting to enter the modern era, a few years earlier the hospital started calling the wards “units,” in order to sound less like what they were, psychiatric wards for the patients no one else wanted or could handle.   The hospital in Norwalk, still functioning to this day, was the dumping ground for patients who were involuntarily committed throughout Southern California.

I was lucky to have been assigned to unit 407, because it was the only enlightened unit in the hospital.  That was due primarily to one remarkable individual, my supervisor, “Dr, Leo.”   Leo was one of  a dying breed; a humanistic psychologist in a hospital that was one of the most inhumane places I had ever seen.   His unit had the reputation of being the only one on the hospital from which patients were ever discharged.  That’s because it was arguably the only unit in the hospital where the patients weren’t trapped in a medical nightmare.

Leo had a “secret sauce,” a therapeutic ingredient that no one else in the hospital had.   That sauce was work.   On his off hours he would go to businesses in the area and convince the owners to hire his patients.   He would then give his patients “passes” to go to work in the community for part of their day.   At work, patients who had been hospitalized in some cases for decades would shed their engrained identities as patients and gain dignity for a few hours a day at a job “on the outside.”  On the inside Leo had a motto that he would recite to patients whenever he saw evidence to the contrary: “There are three things you aren’t allowed to do here: you can’t be sick, crazy or lazy.”

Leo had the glass windows removed that separated the nursing station from the day room, so the nurses and psychiatric technicians couldn’t hide and separate themselves from the patients.   No other unit did that, mostly out of fear for the staff’s safety.  He would smile broadly when he saw you and rub your shoulders; he believed in touching both staff and patients, and we loved it!   He held psychodrama groups daily, with the staff members participating alongside the patients, and although he was a rather funny looking, overweight fellow himself, he led daily exercise groups as well.  He not only gave me permission to run poetry writing groups with the patients, but he connected me with the foremost poetry therapy proponent in LA, who at the time was teaching at LA City College.   And he scolded me for submitting a patient to psychological testing, because he believed that testing should only be done therapeutically and the projective tests I was giving only led to patient regression.

When I worked with Leo it was close to the end of his career, and he appeared to be fighting off his own depression.   When I talked to him about it, it was clear that he was struggling with the medicalization of the hospital (and his beloved wife Frances’ declining health).   The new medical director put psychiatrists in charge of each unit, when previously the staff member who earned the most respect, regardless of their position, had led each unit.   And a renewed push was placed on medication as the only legitimate treatment method; the humanistic changes that Leo made on his unit were being pushed to the side.

Leo has long left us, and while I am not a big believer in heaven or hell being anywhere other than on earth, if there is a heaven outside of 407, Leo is there rubbing everyone’s shoulders.

 

 

And Who Dies?

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images-1More than 150,000 people will die today, according to the CIA (and who better to get our statistics about death from?). I think about dying almost as much as that other thing men think about practically all the time. And frankly, I don’t really understand people who don’t.

In “A Year to Live,” Stephen Levine gives an account of how he lived a year of his life as if it were the last: “One of the first beliefs we come across is that the only reason we imagine we will die is because we are convinced we were born. But we cannot trust hearsay! We must find out for ourselves. Were we born? Or was that just the vessel in which our timelessness momentarily resides. What indeed was born? And who dies?”

What was born? Who dies? Jeez Louise. The conclusion, I suppose, is to question whether that bag of bones we call our selves has anything to do with the essence of who we really are. We are, Levine suggests, timeless.

This is a compelling thought, because I have wrestled with the notion of time almost as much as I have wondered what my life would have been like if I wasn’t born with this terrible nose. Time, I have suspected, is the construct that grants our non-corporeal souls the illusion of mortality. Yup, I really meant to say mortality, because that is the illusion at least as much as immortality is. (I am not a big fan of Newtonian time, which suggests that there really is such a thing. I am closer to Kant, and think that time is primarily that thing that humans create to aid their quest for survival. Sequencing events allows us to predict more accurately, and the more accurate our predictions, the more likely our arrow will end up in the bison.)

As I age, I cling more to life than I did when I was younger and had more of it left. That thing I cling to, of course, is my corporeal life, because as much as I might believe in an afterlife, I don’t know whether it is going to look more like Tahiti or Detroit. And that clinging is certainly a bad thing, because sooner or later I am going to have to let it go, and I am so ill-prepared.

There was a very brief reality TV series back in 2006, an American adaptation of a British series called “The Monastery,” in which a group of 5 men from LA was sent to live in a Benedictine monastery in New Mexico. In one episode, the men were taken to visit the hermit, which was a very honored role within the monastery. One of the LA businessmen asked the hermit what he did all day, and the hermit said incredulously, “preparing to die.” The businessmen looked at each other, puzzled, and one of them finally said to the hermit something to the effect of, “Doesn’t that seem like a waste of time?”

To that, the hermit responded crisply, “I can think of nothing in life more important to do.” The LA businessmen chuckled uncomfortably. Maybe they had more important things to do.

Sleeping in Security, Waking in Happiness

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images-2 With apologies to Coleridge, behavior analysts are capable of “all things great and small.”  You might recall the story of Skinner covertly conditioning a hand waving response in a Freudian nonbeliever at a meeting in the psychology department at Harvard.  In case you haven’t heard it, Skinner was attending a faculty meeting when a guest psychoanalyst was criticizing behaviorism. Skinner wrote a note to the colleague sitting next to him, saying something like, “watch while I condition a hand-waving response.”  Each time the analyst gesticulated with his hand, Skinner smiled at him.  Sure enough, after a while, the analyst was waving his hands wildly.

If behavior analysts have the skills to covertly condition a hand waving response, teach a child with autism to talk, teach me how to tie my shoes (I need a refresher on this one), and keep people awake at nuclear power plants, then certainly we have the skillset to contribute to making the world a kinder, more peaceful place.

Behavior analysts, and psychologists in general, have often tried to extend their reach and apply their knowledge not only to the lives of one human at a time but to humanity as a whole.

Montrose Wolf, one of the pioneers and creators of the term “applied behavior analysis,” moved to Kansas primarily because it was there that he was given the opportunity to create solutions for problems of segregation and poverty.  Skinner, whose shoulders Wolf and other behavior analysts stood on, wrote “Beyond Freedom and Dignity” (and perhaps “Walden Two”) in order to address societal ills, and psychologists from nearly all disciplines have typically expanded their focus from the individual to society at large, often toward the waning years of their careers.

Not long ago, a conference entitled “Behavior Change for a Sustainable World” took place in Ohio; behavior analysts from around the world met to discuss how they could use their skills and knowledge to combat climate change and other threats to a sustainable world.

Most behavior analysts I know are overwhelmed with the challenges of helping even just a handful of children, as the rest of us are often bogged down daily with the tasks of caring for our families and ourselves.   So it is only for the purpose of inspiration that I present to you these thoughts:

22 years ago, while under house arrest, Myanmar’s democracy icon Aung San Suu Kyi won the Nobel Peace Prize, a prize she could not claim until just a year and a half ago.  When she finally appeared before the peace prize committee, she gave one of her typically extraordinary speeches.  (You can read it in its entirety here.)

When referring to the international plight of refugees, Suu Kyi said the following:

“Ultimately our aim should be to create a world free from the displaced, the homeless and the hopeless, a world in which each and every corner is a true sanctuary where the inhabitants will have the freedom and the capacity to live in peace.  Every thought, every word, and every action that adds to the positive and the wholesome is a contribution to peace… Each and every one of us is capable of making such a contribution.  Let us join our hands to try to create a peaceful world where we can sleep in security and wake in happiness.

Aung San Suu Kyi

You Could Have Killed Us

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imagesMost people have a good idea what corporal punishment means in plain English, but behaviorists like to use words precisely.  Punishment, to a behaviorist, is something that happens following a behavior that reduces the likelihood that the behavior will occur again.  Punishment comes in two main flavors: positive and negative.  Positive punishment is when you add something to a situation, like a slap on the butt, an electric shock or a spray of a noxious substance on someone’s face.  Negative punishment is when you take something away, like a favorite toy, a trip to Disneyland, or the cell phone your wife was using to text the pool guy.  It is considered punishment as long as it reduces the behavior that came before it.

Corporal of course means having to do with one’s corpus, or body, so by definition when most people think about corporal punishment they are thinking about the positive kind, at least in behavioral terms.  Positive and negative have always been tricky words in behaviorism, because they don’t translate well into common parlance; most non-behaviorists like to think of corporal punishment as negative and taking bad things away from people who misuse them as acceptable, if not positive.   I am sure I am not alone in thinking that behaviorists long ago should have substituted the words “additive” and “subtractive” for positive and negative, but it is too late and too far into the game.

Two corporal punishment incidents in which I was personally involved occurred when I was in college and when I was in my late forties and taking flying lessons.   The flying incident occurred when my septuagenarian instructor slapped my hand sharply as I reached for the mixture control instead of the carburetor heat in a little Cessna 150.  We were on the deadly base-to-final turn in the pattern and a power reduction at that altitude and in that attitude could have led to the infamous “graveyard spiral.”  “You could have killed us,” he said after the slap.  He was absolutely right, and I thought twice whenever I reached for the mixture control.

When I was in college my fencing instructor, sans helmet, was demonstrating to each of us a particular technique that required our foils extended toward his face.  “Whatever you do, don’t lunge at me,” he warned.  When he reached me, I extended my weapon and instinctively started to lunge.   Before I knew it, he whipped the side of my knee over my pants with his foil, which stung like hell and left a welt that lasted a week.  Without his helmet on, I inadvertently could have taken out an eye or ruptured his carotid, and frankly I deserved the punishment.

I can think of a couple more instances of corporal punishment I endured, and I don’t believe I was worse for the wear.  Research tells us that the improvements in kids’ behavior following “positive punishment” tend to be short-lived and have some adverse side effects (such as teaching them to be physically aggressive), so before you post angry and misguided comments, please note that I am not a fan of corporal punishment as a disciplinary method for children.   In fact, perhaps one reason it might have been effective for me as an adult is that I wasn’t immunized against it as a child (although threatened with the belt on many occasions, it was never used).  Also, injuries were minor (the bruises were chiefly to my ego), and my behavior, though not intended to hurt anyone, rationally warranted the punishment.   The fact that both instances mentioned above could simply have been designed to save the lives of the punishers is not lost on me, but that doesn’t mean that I did not reap some benefit.

 

What makes good teachers great?

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OldTeacherIntro-2

PJ O’Rourke once wrote that corporal punishment should be reintroduced into schools, but used on teachers. I might agree, but for the fact that I have had some incredibly good teachers over the years.

I once heard that you can teach a good teacher to be a better teacher, but you can’t teach a bad teacher to be a good teacher. From supervising and consulting with special education teachers to working alongside them, to having been a student of teachers and a teacher of students myself, I have come to believe that what makes teachers good is that they start off with simply being a good human being. That is to say, they are kind, receptive, curious, not terribly judgmental or jaded, and enthusiastic. I don’t believe that good teachers need to be very smart, or even that emotionally stable, although that latter quality certainly helps. I also don’t believe that being a good human being necessarily makes one a good teacher– only that it is the source from which all else springs.

Good teachers, I believe, have in common the ability to listen, and active listening, as it is so often called among psychologists, is quite a skill. It is the sine qua non of understanding, and understanding is the foundation of intimacy. Intimacy may seem an odd word when it comes to teaching, because it implies a two-way street, and that aspect of learning isn’t always clear. In an age in which much learning takes place while passively watching online videos, it is hard to say that there is much intimacy going on. But there is even a sort of intimacy that can be created digitally, or as we used to say, over the airwaves.

Vin Scully has said that when he broadcasts he imagines that he is talking to one person. Listening to Vin Scully broadcast Dodgers games feels as though you are engaging a warm, charming friend. The best online video experiences, in which my attention is most riveted, occurs when I feel as though the presenter somehow knows me, is somehow interested in me. That is perhaps one reason why the phrase “death by PowerPoint” has become so popular among presenters. Bullet points on a screen may as well be bullets pointed at the audience.

But when I look back at the teachers from whom I learned the most, one of them in particular stood in front of his statistics students and practically read from his lecture notes. The fact that Charlie Moore was a sweet, kind and unpretentious man peeked through his dry monotone and that was what made you want to listen and learn what he had to say. And after class, any student could stop him in the hallway and he would give you his full attention, making you feel as if he truly cared about what you had to say. That kind of kindness, that kind of intimacy, is what makes a good teacher great.