Lecture 6: The Making of a Psychologist: Fester Bestertester Returns! (In Memory of Don Martin, MAD magazine, and my mad, pre-pubescent youth.)- Part 2

So, a man walks into a doctor’s office and he says, “Doctor, help me!  I’m depressed and want to kill myself.”  What is the first thing the doctor is supposed to say?  “Tell me about it?  How do you feel about that?”  No, you are supposed to ask, “Do you have a plan?”  If he has a plan, you have to call the police.  This has become universal truth among mental health professionals because it is the law. 

Some of the more enterprising of us would give that man a Beck Depression Scale.  Considering the Beck in light of the best made plans of mice, men, and psychologists, this guy is just as likely to answer all the questions in such a way as to produce a low score, meaning that he is a happy guy and has lots to look forward to in life, even though he may not really be.  Why might a test score not be consistent with his complaints upon interview?  Because the Beck has high face validity, meaning that almost anyone would know what the questions are getting at because no effort has been taken to conceal the purposes of the test items. 

Why would a person not want to answer questions honestly?  Maybe because the man is concerned about leaving a paper trail so that someone can use the results against him.  Maybe because he came to see a therapist as to a priest and expects both confidentiality and sanctity to be displayed in his treatment, but will present the better side of his nature, however insincere, if he thinks his answers may be viewed by others outside his therapist’s office.  He might also adulterate his responses to the Beck because he was raised to believe that you should not complain because people don’t really want to know about your problems.  (“How are you today?”  “Fi-i-ine.”  Insert smile here.)

I should add at this point that the reason most mental health professionals administer the Beck in clinical practice is to cover their bum.  That way, if the man does something stupid, like attempt suicide after you discharge him from your care, you have a piece of paper that will say to any licensing board or court of law that he was not depressed at the time he left your care.  See, the test proves it!  This, incidentally, is frequently what happens in psychotherapy.  A patient will lie to a therapist or reveal less than the truth with the idea that he only wants therapy to find a solution to a very restricted area of stress. 

Take as another example, the patient who sees a mental health practitioner for depression for years, takes a variety of pills from a psychiatrist and/or does behavioral or insight oriented therapy with a psychologist or counselor, but never reveals that he was severely abused sexually and physically because it is both too embarrassing and too painful to discuss even with the treating doc. 

“So, what is testing supposed to do?” you or someone might sneeringly ask who has had his or her deepest, darkest secrets revealed by some yokel writing a blog in the middle of nowhere with a Doctor of Philosophy degree from some Podunk town in Indiana.

Testing is supposed to reveal things about you, in this case about your personality, which cannot be revealed in any other way.  It is meant to be a way to shed light on a set of psychiatric symptoms, to provide additional information about your clinical picture.  It is not meant to be the picture itself.  For this reason, the Beck is not expected to replace the way you report your own symptoms in therapy, but to provide some basis to view progress in treatment.  It is no better than a snapshot of someone who is smiling for the camera.  The subject knows that a picture is being taken and smiles accordingly, even if he has a plan to commit suicide afterward. If the patient reports severe depression, but the test says that person is happy, you have something meaningful to work with because it gives you the opportunity to explore the reason for the discrepancy, an exploration that can be very meaningful.  It should not work as a defense in court, if a patient discharged from the hospital with a normal Beck score, walks onto the freeway during rush hour and is returned to the hospital in a mangled state or else deceased.  However, there are always exceptions.  A court may see the results of this test as proof that the patient became suicidal after, not at the point of discharge.

Regardless of what we know about psychological tests and the Beck in particular, psychiatrists frequently want to use the Beck in this way.  Anytime there is a question of self-harm upon discharge, the question most frequently asked by MDs is, “Did you give him the Beck?” 

Lecture 6: The Making of a Psychologist: Fester Bestertester Returns! (In Memory of Don Martin, MAD magazine, and my mad, pre-pubescent youth.)- Part 1

From the above arguments, one may well conclude that MDs don’t know what a Psychologist is supposed to do or what they know how to do.  In most cases, this is correct.  However, in defense of my professional antagonists, I can report on good authority that many aspiring Psychologists don’t know what they are doing either or what they are getting into, that is, until they arrive at the university where they are to be trained, the truck pulling up packed with furniture and dishes, suitcases in hand, with their spouses and pets about to enter a new house in a new town, sometimes thousands of miles from their home.  And, depending on your previous training, the change can be overwhelming especially when you discover that everything you learned previously no longer applies.

This was my situation and also the situation of most of my peers.  Much like in the military, we were about to be transformed from couch potatoes, drones of the hive as it were, then broken down, to be built up again as fully functioning, worker Psychologists to go out to the field to extract knowledge like honey.  Well, this may be true for some people anyway…

In the Beginning, most people enter this field because they want to help people.  At least in my case, my master thesis was not taken seriously and, indeed, it embarrasses me even now, although I still keep a copy of it.  In an essentially non-academic Master’s program, such as mine, they teach you various methods of counseling and counseling theories.  The statistical requirements are minimal.  You are given enough information to know how to read a bar graph or pie chart.  In short, by the time you finish a Master’s degree in psychology from a program that is not tracked for further education, you are trained to counsel and, it is hoped, pass an exam to be a counselor.

Contrast this with Ph(ony) D(octor) training in Psychology.  By the time they finish with you, you are trained to study human behavior with a microscope and may even know something about the functioning of the brain itself.  This can be a little disconcerting if you have the notion that you are studying Psychology for some other reason.  At least in my doctoral program, if you had the idea that you were training to be a PhD because you wanted to find out more about how to help people survive or do anything else useful for them, you were very soon disavowed of this notion.

What does a psychologist learn? one may well ask.  Why, testing of course!  A good doctoral program will teach you how to do psychological research and testing, which you will realize if you think about it for any length of time, are both essentially the same thing, one applied to groups and the other to individuals.

I remember well how this bit of information met my ears and bore into my brain.  “Testing?” I said to myself incredulously.  “What in blazes does that tell you?”  I have since found out the answer to that question because I had become so disoriented by the unexpected and overwhelming situation in which I found myself that I did my cognate (minored) in Psychological Testing.  Frankly, I didn’t know what else to do my cognate in.

So, when you look at me now almost 20 years after completing my degree, what do you see?  A psychologist who understands what testing is for and how it all works.  I use very few tests with regularity now.  I can approach research in a way that allows me to understand the sleight of hand that gives it meaning.  But, the thing that fascinates me now is the very same thing that has fascinated me since I was a teenager—how can we make something of ourselves as human beings and how can we solve even the seemingly insurmountable problems in our lives.  And I hate to say it, but I still do not consider myself particularly good at testing even though I know how to do it.

 

Lecture 5: The mental health wars: Money Doctors versus Phony Doctors. (Raise your hand if you know anything!)-Part 2

As I entered the Kahuna’s office, I was well aware that my research ideas were too early in their development for me to discuss with him.  Rather, I was told, amidst some snickering, that the meeting was for the Kahuna to get to know me.  I could tell from the smiles that they were questioning whether I would survive the Kahuna’s implacable gaze.

The meeting included three of us—Kahuna, the PSU psychiatrist, and me, the only non-medical person in the room.  Almost immediately upon seating myself, Kahuna shoved a paper at me and asked me in the sonorous Kahuna voice what I thought of its contents.  What he had given me was the first page of an article which contained the abstract of a research study in which two personality tests were structurally analyzed and compared.  Both are still in frequent use today.  As the abstract informed me, the construct “Depression” in each test, which should have been identical or nearly-identical by definition, was shown to be unrelated.  Each measured Depression in a way that was unrelated to the other and, if the construct of their factors was different, meant that they have nothing in common at all.  (If true, these results would undermine the validity of the construct “Depression” in either or both tests, raising questions about both, if not rendering each test useless.) Having read the abstract while the two MDs conversed, I waited for a break in their discussion and the re-focusing of the Kahuna eyeball on me so that I could inquire, “Are you asking me to respond to this?”  Kahuna offered a brief shake of the head, and then returned to his discussion.

(I have since added Kahuna’s abbreviated head shake to my informal list, which is rather extensive at this point, of the number of ways that one can say, F*** you!)

 This long introduction is not to denigrate the person or office of Kahuna, but rather to dramatically illustrate the state of mental health today and show why it is hard to survive in the mental health system, not to mention be successfully treated. 

First, be aware that most, but not all M(oney) D(octors) have little training in research and statistics and that, if they participate in development of medicines at all, their involvement is indirect.  As a result, when physicians review articles, they mostly are looking at abstracts, more specifically at the results, not at the way the research is designed.  It is as if they have no idea that a study’s design can influence outcome or that a design can be so flawed that no question is answered.  The results of such flawed research may in itself be useless, but may nevertheless be published. 

But, Kahuna showed no interest in my thoughts about the abstract nor was he interested in what my years of study in research and statistics informed me about the merits of the abstract he had given me.  Given the easy with which he handed me the abstract, I suspected that he kept several copies in the top drawer of his desk to dispense to psychologists under his supervision as a reminder to them of how irrelevant their profession is, at least to him.  As my imagination was running away with me at that point, I also thought that he must have had a drawer full of multicolored, multi-shaped pills to pull out so that any upstart psychologist might better understand what he or she was truly up against, the entire medical profession and the drug companies. 

Compared to physicians, most psychologists have to take a year of statistics along with classes in research development.  All this to learn methods that may permit light to be shed on a grain of sand that sits somewhere on a beach among other similar grains so that, in the end, a Ph(ony) D(octor) may be eligible to provide some sort of therapy to patients, an exercise which many  psychiatrists see as useless when compared to the more effective pill-swallowing procedure.  The techniques or therapy, even as practiced by a psychologist, is most often just loosely related to anything they may have studied and almost certainly is unrelated to any research they may have done to earn their degree.

“So”, you might ask, “who is better trained?”  I still recall the startling argument rom one of my professors that PhDs were better trained.  He said that Medical Doctors are technicians who study the body, much in the same way that a mechanic fixes on a car, while we Doctors of Philosophy, no matter the field, are trained in the philosophical discipline underlying our area of study and are, therefore, better able to do research and to reveal new knowledge, knowing how to approach a problem progressively, logically, and syllogistically, from x to y to z etc., with greater discipline.

 “So, who is better trained?”  Well, it sort of depends doesn’t it?

For the layperson, almost certainly, it depends on which profession is better positioned politically and who is paid more money.  Ask Kahuna!  If he says psychological testing and research is ridiculous, then there is an entire institution that will follow him in that assertion.  But the best answer is that sometimes Kahuna’s nostrums will work as promised and other times they won’t. However, occasionally something else less intrusive is required, maybe a little sound advice about how to weather an emotional storm or what to look for to make better judgments in order to increase the possibility of Survival. 

If we were all so dependent on pills to manage our moods with the purpose of making us better adapted as survivors, we would never have left the caves, but may still be waiting for extra-terrestrials to deliver our medication on time and in the proper dose so that we may continue in our evolution to our rightful place at the top of the food chain in front of the television.

Lecture 5: The mental health wars: Money Doctors versus Phony Doctors. (Raise your hand if you know anything!)- Part 1

In the late 1990s, this fearless author took work as a psychologist at the Psychiatric Services Unit (PSU) of his local jail, a service that was provided by our State University, through a Federal court order.  (See “Jail as a Psychiatric Emergency Room” in American Jails, September/October 1998.)  It was his job to clinically supervise counselors and social workers in the provision of mental health services to jail inmates.  Services included intake evaluation to insure that mentally ill jail inmates got necessary treatment from the time they were received into the facility until discharge.  It included crisis intervention and counseling in order to minimize risk to inmates and correction officers.  At the beginning of the University’s involvement in PSU, there was some enthusiasm for the new program.  The PSU psychiatrist was especially enthusiastic about doing research among the jail population and he actively encouraged me to think about the kind of research I would like to do.

For those readers who are unaware, research in most fields is typically framed in response to previous research in that field.  To begin a study, a researcher does what is called a literature review, that is, a survey of research that preceded and is relevant to the topic of interest so that previous knowledge can be extended through your efforts.  If you have ever wondered why so much scientific literature, particularly in psychology, seems overly precious, abstract, and not practical, it is because this attention to previous research to formulate future research projects causes researchers to study individual psychology through a lens that is ground in an academic environment rather than in the real world.  After all, that is where scientific literature mostly comes from.  The faculty is required to research (publish or perish!) and graduate students are trained to do research with the idea that they will first join the faculty in their efforts, then replace them.  For this reason, one may think of a university as a research factory.

Perhaps more than in most fields, psychological research is scrupulous in the use of research and statistical controls in order to obtain reliable results in an area of study.  To accomplish this, any investigation must control for the effects of extraneous and random variables.  The problem is, of course, that the researcher is trying to control variables that are in all likelihood represented chaotically in subjects’ brains as a result of daily experiences that have occurred throughout individuals’ lifetimes.  For a researcher, this is almost like a judge directing jurors not to discuss a case during criminal proceedings.  The jurors may comply with the order, but there is an equal likelihood that they will not.  The same is true when applying rigorous research procedures to the chaos of the human brain. 

(I recall, as a young man, being called for jury duty on a celebrated murder case, one that I had not followed in the media, but of which I knew some details.  The judge directed the prospective jurors not to discuss the case as we waited to be called into the courtroom in groups of 12 for voir dire.

 [http://www.legal-explanations.com/definitions/voir-dire.htm] 

Most of us went onto the balcony for air.  Within minutes, I heard someone in our group proclaim with more than a little irritation, “I know he’s guilty!”  So much for the sanctity of the judicial system!  Just think of all those brains laboring under the order of that particular judge.  Then, imagine those same brains laboring under the scrutiny of a researcher trying to follow predetermined procedures to ensure that the influence of extraneous or random factors are controlled or eliminated.)

Despite all this, in response to our psychiatrist’s excitement, I began to think about the kind of research that would be useful and that I would find interesting.  Strangely, I found that my thinking drifted more into the area of economics than psychology.  Specifically, I began to think about jail economics with an eye for how a very restricted economy would affect individual and group decision-making.  My thinking was that, if a comprehensive list of valued commodities in the jail could be derived– for example prescribed and contraband drugs, shanks and other weapons, and sex toys (human and otherwise), for example– and the flow of commodities somehow tracked, that a number of important socio-economic and psychological issues would emerge, including power differentials, affiliations, and community stressors that impact inmate psychology.  In my imagination, this type of information would be useful in doing psychological assessments and providing treatment at the jail.  It may also, according to my thinking, allow rare insight into environmental stressors that could possibly be used to reduce discontent among the inmates and prevent riot.

The idea, I knew, was creative and was likely not doable.  But, as I thought, the attempt alone would be useful in uncovering important variables that contribute to the uniqueness of the jail community and that influence the various psychologies of inmates, officers, and staff, everyone in the jail community.  As I was lost in contemplation of how I would proceed with this innovative research topic, the psychiatrist said that I had to meet the Great Kahuna, the feared psychiatrist who supervised him and ultimately the entire PSU project.

NEXT:  The mental health wars: Money Doctors versus Phony Doctors. (Raise your hand if you know anything!)- Part 2.  Meeting the Great Kahuna