A Battle for the APA’s Soul

As the controversy has grown about waterboarding and other “enhanced interrogation” techniques used with suspected terrorists at Guantanamo Bay and other secret prisons around the world, the role of psychologists in these practices has also become the focus of intense debate. At its annual convention this summer in San Francisco, the American Psychological Association (APA) specifically proscribed its members from assisting directly in more than 20 kinds of interrogation procedures, including those involving prolonged isolation, sensory deprivation, and sensory assaults. It also reaffirmed the duty of psychologists at these facilities to report any abuses they witness and threatened sanctions against psychologists who fail to do so. Nevertheless many critics continue to insist that APA hasn’t gone far enough.

Specifically they’ve urged the APA to follow the lead of the American Psychiatric and American Medical associations, which have forbidden their members from associating even indirectly in the enhanced interrogations of suspected terrorists. Among the most recent higher-profile protestors of the APA’s policies are psychologist and bestselling author Mary Pipher, who’s returned her 2006 APA Presidential Citation. Marybeth Shinn, past president of two APA divisions, and Uwe Jacobs, clinical director of Survivors International, have publicly resigned from the organization. In addition, six college and university psychology departments have formally called for the APA to strengthen its prohibition, and more than 220 members of the organization have pledged to withhold their dues in protest. These protests have been accompanied by a wave of negative media coverage, including articles in Harpers, the Chronicle of Higher Education, Inside Higher Education, the New Scientist, and the online version of Newsweek.

The APA continues to insist that psychologists can play a vital role in helping interrogators control their excesses. Without psychologists to report abuses, the organization maintains, the detainees would truly be left alone, subject to their interrogators’ frustration and sadism.

Critics remain unconvinced. They say the APA’s position is merely a self-serving attempt to safeguard billions of dollars of contracts with the Defense Department and to protect its many members who have military ties. Even if the APA truly intends to protect detainees, they contend, for psychologists working within facilities where abuse is rampant and the entire chain of command may be complicit, their complaints will go nowhere, and they merely lend an aura of legitimacy to a system of prisons that violates international law.

This argument has been underscored by Robert J. Lifton, famous for his study of the role of doctors in Nazi Germany, who’s said, “Psychologists are meant to heal and not break down, and therefore any consulting or involvement in interrogations . . . should be prohibited by the American Psychological Association.”

Motivating Depressed Clients for Therapy

Every therapist knows that clients’ ambivalence about change is a primary obstacle to effective treatment. Now there’s increasing evidence that an approach called Motivational Interviewing (MI), can help directly address clients’ mixed feelings about being in therapy.

Originally developed for work with alcoholics, a notoriously difficult treatment population, MI incorporates old-fashioned Rogerian principles of empathic listening and genuine respect for the client’s perspective. It draws on the work of change theorists James Proschaska and Carlo DiClemente, which identifies the distinct stages ambivalent clients need to pass through to develop a more proactive engagement in therapy. Instead of emphasizing prepackaged treatment protocols, MI “rolls with clients’ resistance rather than butting up against it,” in the words of Allan Zuckoff, of the University of Pittsburgh School of Medicine.

Zuckoff and colleague Holly Swartz were especially distressed about the high numbers of depressed African American women who came to their clinic for intake sessions but never showed up for their first therapy appointment. They suspected that the therapists’ assumptions about what the clients needed and thought interfered with their ability to listen deeply to the women and draw out their commitment to treatment.

They then became interested in ethnographic interviewing (EI), a technique used by sociologists to interview people of other cultures that helps interviewers keep their own cultural biases from distorting the conversations. They wondered whether they could combine principles of EI and MI to develop an intake session that would help enhance depressed African American women’s intrinsic motivation to change.

Zuckoff and Swartz developed a single-session intake session that helps therapists open their ears and clients fully express their ambivalence about therapy. In their small study of the intake model at a community clinic, 23 of 24 depressed African American women who received the session kept their first therapy appointment, while only 7 of 33 who didn’t receive the intake session did.

They describe the session in the August Professional Psychology: Research and Practice. Therapists first elicit the client’s story, using reflective listening and empathic questioning, and making sure to ask both about feelings—”You’re stuck with all these bills and busy all the time. How’s that affecting you?”—and the situation—”You’ve been feeling hopeless lately. What’s been going on in your life that might be causing this?” They invite clients to fully air their ambivalence, talking about both their hopes and fears about treatment, and any external barriers, such as transportation problems, lack of child care, or unsupportive spouses. They tie feedback and information to what the client has said, never using it to push or persuade. Finally, summarizing both the situation and anything the clients have said that indicates their readiness to change, they ask whether they’d like to give therapy a try.

The paradox of the MI approach is that clients who fully express ambivalence are more likely to locate their intrinsic motivation to change. “MI is really about therapeutic humility,” says Zuckoff. “It helps therapists stay out of their own way.”

Educational Baby Videos Flunk

In the DVD Baby’s First Moves, from Disney’s popular and immodestly named Baby Einstein product line, a baby, a loveable puppet insect, and some fanciful animated figures crawl around as the voiceover repeats “Crawl” and Mozart’s “Eine Kleine Nacht Musik” plays continuously. The DVD is marketed for a prelanguage age group.

Baby educational products like these, a $100-million-per-year business, don’t make any promises beyond claims about helping parents spend “quality time” with children, or helping children develop, but there’s an implicit message: such products make babies smarter. Even if they don’t really help, one might think they can’t hurt.

Now a study by University of Washington associate professor of pediatrics Frederick Zimmerman and others, reported in the October Journal of Pediatrics, finds they may actually impede language development. For infants aged 8 to 16 months, every hour spent watching one of these videos corresponds to a lost opportunity to learn six to eight new words—a 17 percent drop in vocabulary compared to children who don’t watch the videos. The study also looked at older infants, aged 17 to 24 months, who watched children’s (as opposed to babies’) educational electronic media, finding that only the baby educational videos were associated with the drop in vocabulary formation.

Zimmerman suspects the drop may relate to what parents have instinctively known forever: babies’ brains develop primarily through interacting with adults. Changes in the pitch, volume, and rhythm of adults’ voices, their changing facial expressions, and games like peek-a-boo stimulate neural development. Videos and DVDs can’t replace this type of interactive feedback during a critical period of neurolinguistic development.

The study adds the important caveat that association isn’t causality: the videos themselves may not be harmful. Many parents may buy them for babies who are already facing cognitive challenges, either because of physiological problems or because their parents are too exhausted or overscheduled to interact with them. But, says Zimmerman, given the negative association with vocabulary development and the absence of any evidence that these products are beneficial, he’d advise parents to avoid them and not try to replace face-to-face interaction with technology.

Different Alcoholics, Different Treatments

As the idea that 12-step, total abstinence is the one best treatment and goal for alcohol dependence (AD) fades, it’s become important to think about different kinds of people with alcohol problems, rather than seeing them as a single, monolithic group. Now for the first time, a national survey based on a study of 1,484 Americans, led by Howard Moss of the National Institute on Alcohol Abuse and Alcoholism and reported in the January issue of Drug and Alcohol Dependence, describes a typology of individuals with AD, which may help target treatments.

The largest and least severe subtype, Young Adults, who averages 24 years of age and represents 31.5 percent of those with AD, though only 8.5 percent of them have ever sought treatment. They drink on fewer days than the other groups, but are the most likely to binge. This subtype generally hasn’t yet run into financial, social, or legal problems from drinking. Some of them straighten out, often without professional help, while others move into one of the more severe subtypes.

The next two groups are called Functional and Interfamilial. Including individuals in their late thirties to early forties, both groups have steady jobs, but they drink more often than Young Adults and are near or just over the brink of getting in serious trouble from drinking. Those in the Functional group still believe they can manage their lives: they have the highest income of all the subtypes and only 17 percent have sought help for drinking. Those in the Interfamilial group, while still holding down jobs, are in deeper waters and have begun to realize it. They’re more likely than Functionals to have family histories of AD, to suffer from major depressive, obsessive-compulsive, bipolar or anxiety disorders, and to use other substances in addition to alcohol. Some 27 percent of the Interfamilial group has sought treatment.

The two most severely affected groups—Young Antisocial and Chronic Severe—fit the common perception of people with AD. They’re the most likely to have antisocial personality disorder and a history of legal, personal, and financial troubles. The primary difference between these groups is that the Young Antisocials downplay the negative effects of their own drinking, while the Chronic Severe group no longer does.

Moss feels it would be helpful to use these types as a guide to determine which treatment approaches to use. The more severe types require the most intense, multifaceted interventions and complete abstention, he thinks. But it may be counterproductive to automatically approach the less severe types with stern interventions and demands for total abstention. Because they haven’t paid a price for drinking and may, in fact, be able to maintain their lifestyle and control their drinking, abstention is less likely to be a goal that engages them in treatment.

Does Therapy Breed Isolation?

Even in the absence of empirical evidence, most therapists assume that the supportive therapeutic relationship enhances clients’ abilities to have successful relationships with others. Why, some might argue, waste time researching something so self-evident? Not so fast, says Harvard psychiatrist Richard Schwartz, “The conviction that psychotherapy is good for social adjustment turns out to be largely an act of faith,” he says.

To support his claim, Schwartz points to the large Stockholm Outcome of Psychoanalysis and Psychotherapy Project in 2000, which looked at therapy’s long-term outcomes. The project found that after therapy concluded, patients who underwent psychoanalysis and psychotherapy engaged significantly less with other people—a decline in social functioning found even among those whose therapy was considered successful.

Almost all the empirical evidence showing that psychotherapy improves other relationships comes from studies of people suffering from depression or schizophrenia. But treatments for these conditions usually explicitly focus on expanding social functioning. Schwartz’s concern is that too many clients wind up substituting their relationship with their therapist for outside relationships, a situation that the Swedish study suggests may be the case.

Since Schwartz wrote about his concerns in the September/October 2005 Harvard Review of Psychiatry, he still hasn’t seen any more research on therapists’ impact on clients’ social connections. In the absence of data confirming or contradicting the Swedish study, Schwartz strongly advises therapists to focus on how clients spend their time outside of sessions and with whom.

Abused Children of Iraq War Soldiers

We hear almost daily of the soldiers killed and wounded in the Iraq war and of the high incidence of PTSD. But for several years, there’ve been only hints and whispers about another long-term problem in the making: how parents’ deployment affects their children.

Anecdotal reports from school counselors note that children’s discipline problems rise and grades fall following a parent’s deployment. A small study in the January 2007 journal Military Medicine by physiologist Vernon Barnes found that adolescents with a deployed parent were more likely to have elevated physical and emotional stress levels. A 2005 report from the Military Family Research Institute of Purdue University (MFRI) notes that many adolescents with a deployed parent report symptoms of depression.

The armed services often point to the unique strengths and resiliency of military families, who draw on pride, a family history of service, and the considerable formal and informal support systems the military has in place. Clear data on the effects of deployment on families has been missing, however, and it’s especially important for this war, which has a higher percentage of married soldiers with children than and an unprecedented level of multiple deployments among Reservists. Now a study in the August 1 Journal of the American Medical Association sheds more light upon the effects of deployment on families.

The research team, led by senior analyst Deborah Gibbs of the Children’s and Family Program at the research institute RTI International, was granted access to Army databases that record every instance of child neglect or abuse among military families. They found that during the 40 months between September 2001 and December 2004, there were 3,334 reports of child maltreatment against 2,968 children. Child maltreatment during deployment was 42 percent higher than during nondeployment. Physical abuse in families with a deployed parent was almost twice as high as in families without a deployed parent, and the parents most likely to mistreat their children were white female civilians.

The Army is already aware of this problem. In response to two smaller-scale studies that yielded similar results, it instituted several programs, including family support groups, Family Assistance Centers offering streamlined referrals to other agencies, and respite child care, to help caretaker parents cope with stress. But Gibbs’s study suggests that much more needs to be done.

Exercise Outraces Depression

While more than 20 years of studies have found that exercise is an effective treatment for depression, matching that of antidepressants, most of them have been hampered by methodological shortcomings. Now, for the first time, a study by researchers from Duke, Emory, and the University of North Carolina, reported in the September Psychosomatic Medicine , addresses these shortcomings and supports the earlier findings. Led by Duke University psychologist James Blumenthal, it finds that following four months of treatment, exercise and medication (Zoloft) worked equally and significantly well on mild, moderate, and severe depressions.

Previous exercise studies haven’t teased out how much of the improvement was due to the exercise itself, how much to the social support from researchers and fellow exercisers, and how much to the subjects’ expectations that they’d improve. Blumenthal solved these shortcomings by using four groups: 51 participants attended three supervised, group aerobic-exercise sessions per week; 53 did the same regimen at home (keeping logs and being monitored periodically); 49 took Zoloft; and 49 took a placebo. About 45 percent of each of the active-treatment groups improved enough to put their major depressions into remission, as opposed to 31 percent of the placebo group. By comparing group and at-home exercise, as well as placebo, the study demonstrates that improvement in depression comes directly from the exercising.

The possible physiological effects of exercise include enhanced transmission of norepinephrine and serotonin and changes in the primitive-brain areas that regulate stressful reactions to both real and imagined threats. It also enhances one’s self-image and a sense of mastery.

Blumenthal points out that his methodology doesn’t answer the question of whether exercise is superior to antidepressants. But if exercise is equally effective for many people and you compare the side effects of exercise with those of antidepressants, it seems to make sense to try exercise first.

Resources

Motivating Depressed Clients: Professional Psychology: Research and Practice 38, no. 4 (August,2007): 430-39.

Baby Videos: Journal of Pediatrics 151, no. 4 (October 2007): 364-68.

Alcoholics: Drug and Alcohol Dependence 91, no. 2-3 (December 2007): 149-58.

Therapy & Isolation: Harvard Review of Psychiatry 13, no. 5 (September/October 2005): 272-79.

Deployment Effects: Journal of the American Medical Association 298, no.5 (August 1, 2007): 528-35.

Exercise and Depression: Psychosomatic Medicine 69 (September 2007): 587-96.