Behaviorism and Mental Health

In a comment on my post on Natural Correction, Nanu Grewal raised a question concerning the addressing of behavioral problems.  This is a huge topic, and I feel the reply warrants a post.  There are others who could do a better job than me, but here’s my take on it.

Traditional behavior therapy starts with assessment.  Take nail-biting as a fairly simple example. Observations are made for a week or so, and the frequency of the problem behavior is measured as accurately as possible.  Next step is remediation.  In this case, say, application of a foul-tasting preparation to the subject’s nails.  Then more monitoring.  Essentially what has occurred is that the problem behavior has been punished by the foul taste, and one expects to see the problem diminish in frequency to the point of extinction.  Further monitoring would occur about a month later to ensure no return of the problem.

Nail-biting is a trivial example, but that’s the paradigm.

The fundamental principles are:

1.  When an action is followed by reinforcement, the probability that the action will recur in that (or similar) context is increased.  (Reinforcement has a rather technical meaning but essentially it means something pleasant.)

2.  When an action is followed by punishment, the probability that the action will recur in that context is decreased.

These principles seem like basic common sense, and indeed they are, but they have also been verified empirically in a wide range of situations.  From a behaviorist point of view, whenever we see habitual behavior, we conclude that this behavior is being reinforced in some way.  For people the primary source of rewards and punishments is other people.

Sometimes we reinforce maladaptive behaviors in our children.  Sometimes the process is obvious.  (“Stop making noise and I’ll give you a cookie.”).  But often the behavioral dynamics can be subtle.  A father, for instance, may derive a certain “macho” satisfaction from seeing his young son misbehave, and may communicate this to the child in almost subliminal ways.  Or even:  the father may have some hostility towards the mother (such a cad!) and subtly encourages the boy to give her trouble.  Etc., etc..

Behavior therapy is firmly based on science, but the application of these principles to the subtleties and intricacies of life involves a good measure of art.  The best text on this subject that I’ve ever come across is A Psychological Approach to Abnormal Behavior by Leonard P. Ullmann and Leonard Krasner (Second Edition 1975).

Behavior therapy was popular in the 60’s in a wide range of contexts, and its efficacy was undisputed.  Then, fairly suddenly, it was gone, replaced by Rogerian-type counseling, or reality therapy, etc., or, more usually, by drugs.  Today, of course, we have cognitive-behavioral therapy, which is not behavior therapy.

Behaviorists focus on specific behaviors.  Many years ago a young woman came to see me.  She was beset with problems:  single mother; alienated from her own mother; no job; depressed; anxious, etc..  She mentioned in passing that she was the “sort of person who never finishes anything,” and that she had seven unfinished knitted sweaters in her closet.  At the end of the hour she was clearly feeling better just for having had a chance to “unload,” and she asked for my advice as to what she should do about her various problems.

“Get rid of the sweaters,” I replied.

“But I paid good money for the yarn and the patterns.”

“Yes,” I agreed, “but they’re causing you nothing but grief.  They sit in the closet ‘leering’ at you, making you feel guilty.”

“I can’t just throw them away.”

“Keep one and finish it this week; give the others away.”

She agreed with this suggestion, and next week returned wearing the completed sweater, looking much more relaxed and functional.

Now I’m not suggesting that this resolved all her problems – but by identifying one specific problem, she was able to tackle this and find some feelings of success and control in her life.  Then we used this paradigm to tackle other problems.

Often with depressed individuals I would suggest that they make the effort to smile at people they encountered in stores and other public places.  Here again, the emphasis is on identifying a specific response that is incompatible with the problem behavior.  (Note that to a behaviorist, depression is always depressed behavior.  We focus on things like the downward cast of the eyes; the slow speech; the slumped shoulders, etc..  Walk the walk; the good feelings will follow).

In my view this entire area is overshadowed by a simple, much-denied fact:  that the vast majority of people who come to a mental health/counseling/therapy setting do NOT come with a view to making changes in their behavior.  This is not a criticism – just a statement of fact.  But it is a problem, because all the major paradigms (including behaviorism) assume that behavioral change is the objective.  So various games are played.

Usually – in my experience – clients just want to have someone to talk to; someone to validate their views and their relationships; sometimes just someone who’ll play “ain’t it awful.”  Now of course we try to  nudge even the most entrenched individuals towards more functionality, but most therapists that I have known (including myself) spend a good portion of their day holding hands (not literally), soothing frazzled nerves; making encouraging noises, etc., as opposed to pursuing behaviorally specific objectives in a purposeful and objective fashion.

But – having said all that – there are still some behavioral principles that can guide our work.  First and foremost, of course:  focus on specific behavior; encourage functional behavior and discourage dysfunctional.  This can sometimes be subtle.  Craziness is a good example.  If a client tells his therapist that he is convinced that the power company is monitoring his thoughts through the electricity meter and reporting their findings to the government, the therapist is likely to “prick up his ears,” so to speak and perhaps even take notes.  Now this is reinforcing, and what this therapist has done has actually contributed (albeit slightly) to the client’s craziness.  What I do (well, used to do, since I’m now retired) is studiously ignore this kind of comment, let my gaze slip to the middle distance, and wait for the client to say something sensible.  The reality is that the client knows that his assertion is not true; that it is nonsense.  He is saying this because it has been reinforced in the past – by family, police, medics, psychologists, etc., etc..

Now I’m not suggesting that my policy of ignoring nonsense will turn things around, but – and this is noteworthy – I heard remarkably little psychotic speech in my office, even though I routinely worked with individuals who carried various psychosis-type “diagnoses.”  I believe – I hope – that I conveyed to these individuals that for an hour a week they could be completely cogent, lucid, articulate people.

Unfortunately, of course, there were a great many other forces in their lives nudging them in opposing directions.  In my experience crazy people never really get cogent until they develop the skills necessary to start experiencing some success in their lives.  Some of the rehabilitation programs are good in this area, but many are just baby-sitting/daycare services, where the staff have thoroughly absorbed the spurious notion that crazy behavior is the result of an incurable disease called schizophrenia.

From a behaviorist point of view the therapist above who “pricks up his ears” is literally teaching the client to be crazy.  Psychotic speech is a skill that has to be learned (i.e. acquired).  Its primary payoff is that it relieves one of virtually all responsibilities and, in developed countries, attracts a regular, if meager, government pension.

Similar considerations apply to problems like depression and anxiety.  Sometimes I would give direct advice based on behavioral principles, but always I encouraged functional behavior and discouraged dysfunctional.  So if a depressed person indicated that he thought perhaps he should get out and about more, I would enthuse appropriately; if he was just wallowing in the sadness of it all, I would be more neutral, etc., though not to the point of callousness or indifference.  Sometimes it’s a fine line.

With painful memories (currently known as PTSD), I would encourage the client to talk about the precipitating incident over and over from different aspects until the memory of the event ceased to be a fear-provoking stimulus.

I realize that this is a bit fragmented (a bit?!).   Behaviorism is really a mind-set – a way of looking at human existence.  It’s a perspective in which human behavior is a natural phenomenon, and the therapist is someone who tries to elicit functional, successful behavior and discourage the opposite.

The central theme of this blog is that there are no mental illnesses and that the spurious medicalization of problems of living represents a tragic wrong turn in human history.

In a comment on my last post, Nanu Grewal raised the question of a natural correction.  In other words, does there come a point where the nonsense is so outrageous that some corrective force emerges which would undermine and even supplant the present illogical system.  In my view this is an excellent question.

I used to think that the insurance companies might provide such a correction, by simply refusing to pay for this so-called treatment (as they did with inpatient substance abuse treatment in the early 1990’s.)

But this simply hasn’t happened.  Indeed here in the U.S. we’ve recently enacted a parity law whereby insurance companies are required to cover the so-called mental illnesses on an equal footing with real illnesses.  This makes it virtually impossible for insurance companies to start clamping down now.

I have sometimes wondered if the cost of the mental health system would become too great a burden on the public purse, and that some corrective measures would be undertaken.  Most public support of healthcare in the U.S. is through Medicare and Medicaid, and it is widely reported that these programs are under a good deal of financial strain.  Most of the suggestions in this regard, however, have been on the lines of requiring individuals to pay more than they already do, rather than eliminating, or even reducing, the mental illness services.  So I see no great ray of hope in that area.

And of course over and above all of this is the fact that a great many people simply like to take drugs, and this is a powerful drive which tends to maintain the status quo.

Through the years there have been a number of individual writers who have seen through the nonsense and who have spoken out fearlessly.  In recent years perhaps we’ve seen a little more of this, but it certainly hasn’t become a groundswell of protest.  But perhaps that is the best natural correction that we can hope for – more and more individuals speaking out, exposing the spurious nature of the so-called mental illnesses and the tragic consequences of the drugs-for-every-problem philosophy.

Anyway, I can think of nothing else on the horizon.  I’d be interested if any readers had any thoughts.  Can you see any natural corrections in the works?  Are there things we could be doing to promote natural corrections?

On June 23, the New York Review of Books, one of the most prestigious literary magazines in the country, published a piece by Marcia Angell.  I’ve mentioned Dr. Angell before.  She had been editor-in-chief of the New England Journal of Medicine  and had come out strongly against the extent to which drug companies are controlling and directing medical research.

Well in this recent article she reviews three books:

The Emperor’s New Drugs:  Exploding the Antidepressant Myth, by Irving Kirsch, PhD

Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, by Robert Whitaker

Unhinged: The Trouble with Psychiatry – A Doctor’s Revelations About a Profession in Crisis, by Daniel Carlat, MD

Marcia does a very nice job of drawing the various threads from these three authors together into a coherent, stand-alone two-part article (which you will find here and here) that is well worth the read,.  She has also written a book of her own:

The Truth About the Drug Companies: How They Deceive Us and What to Do About It. (Random, 2004)

It’s encouraging that this kind of material is appearing in mainstream publications.  Disenchantment with psychiatry can no longer be dismissed as the crackpot ravings of a few disgruntled eccentrics.

Although I am encouraged by the work of Angell, Kirsch, Whitaker, and Carlat, in my view they all baulk at the final fundamental conclusion:  that there are no mental illnesses. The concept of mental illness is intrinsically spurious.  It’s not just that the concept is applied too liberally, or that drugs are misused, etc..   The critical point is that the APA defines mental illness as, essentially, any human problem – and then, voila! – discovers that lots and lots of people have these so-called mental illnesses.

Until this simple logical fallacy is recognized, progress is inevitably going to be slow and sporadic.  But we’ll keep trying!