Reaching the Limits of Our Patients

IN A REMARKABLE COLUMN IN the October Observer, ["Patients and Impatience" 2004] APS President Robert W. Levenson seems to endorse the recent National Institute of Mental Health, or NIMH, proposal that psychological research should focus specifically on patients with disorders. This can't possibly be a good idea.

By this logic, we can learn about cars only by studying them when the wheels have come off. We must learn of contentment by studying despair, of courage by examining anxiety, and of how the mind works by watching it reach the end of its wits. We should probably examine marriage and family by surveying the divorced individuals who now live in separate homes. The analogy to medicine suggests, yet worse, that we should understand the body, promote health, and prevent illness by turning our attention mainly to the sick and the dead.

I'm not making a plea here for positive psychology, just for non-disordered psychology. There is a fundamental logical error in the idea that nothing can be learned about psychopathology from the study of normal populations: the assumption that we can discern what has gone wrong once psychopathology is underway. In fact, there are many cases in which all that can be learned about a disorder must come from normal populations. This is because disorders often create a profound change - they can render the person's psychological history permanently inscrutable. Disorders can change people so thoroughly that their past and yes, even their current state, become unknowable, no longer open to scientific view.

Let me explain. And please forgive me for using an example from my own research, but this is one I know well that certainly applies: The study of thought suppression. I've observed for some time, as did Freud in a different theoretical context, that trying not to think of something can make you think of it more - and that this might have implications for disorders in which certain thoughts or emotions get out of hand. To study this, I've often looked at the paradoxical effects that happen in mind and behavior when you ask normal subjects to follow a suppression instruction - for example, not to think of a white bear.

Thought suppression prompts glimmers of madness. Trying not to think of just any neutral thought elicits a minor obsession with that thought, just as trying to suppress emotional thoughts can yield the unwanted emotion, and as trying to stop a behavior can stimulate exactly the unwanted action. These findings hint at how disorders develop, as they suggest that patients' own attempts at mental control may ironically promote the worsening of their problems.

But here's my point: We could not have found this out from patients. Patients whose symptoms include obsessive thinking are already involved in trying to stop their unwanted thoughts - in desperation, trying to keep their traumas or fears or dangerous ideas out of mind. We cannot instruct them to do this or not, because they are already doing it spontaneously, earnestly, and sometimes permanently. Their problem is frozen in time by the development of their disorder. This is the story of all too many psychological problems. Once taken to the extreme, they are no longer open to experimental manipulation.

Experimentation is the backbone of science. Without experiments, psychological science becomes immersed in an incorrigibly complex multivariate matrix. It is when we move things around through experimental manipulations that we learn how they work. Patient populations are regularly made up of people who have already been experimented on by Mother Nature, sadly, and who have been pushed so far away from any normal point of equilibrium that they have arrived at a new stable state - a disorder. And like people who have gotten involved in an ironic cycle of mental control that has amplified rather than suppressed their unwanted thoughts, many people with disorders have arrived at states in which their causal history is erased.

What do we do when we must study people only after they have changed into the disordered state? Well, we guess about how to bring them back to normal, uninformed by what drove them to an extreme in the first place. We can't tell how they got that way, so in desperation we invent half a dozen unfounded new therapies each week and try them out mindlessly on groups of patients in the forlorn belief that we are at least "doing something." Like the therapist who recommends the (highly ineffective) therapy of "thought stopping" for an obsession disorder, we try to eliminate the symptoms rather than working to understand the problem.

Psychology can't learn about how people become disordered by studying the disordered person alone. Disorders often cover their tracks, leaving no sign of their origins. Yes, we should do everything we can to fight psychological disorders and aid people who suffer from them. But psychology must be a science of the center of the human experience because we cannot understand the tragic extremes of such experience by looking at them in isolation.

- Daniel M. Wegner
Harvard University

Don't Overlook Clinical Issues

I STRONGLY SUPPORT BOB Levenson's views about the need for more basic psychology researchers to consider mental health issues earlier, more often, and more seriously in their work [Observer, October 2004]. I was trained as a cognitive psychologist and work as an evolutionary/social psychologist interested in individual differences. I've taught a couple of graduate seminars on psychopathology at the University of New Mexico PhD training program, which is about half clinical and half experimental students. I got interested in such issues when my step-son developed schizophrenia, and when my wife became active in the National Alliance for the Mentally Ill.

Here's my take on the current situation: APS-type research psychologists typically overlook clinical issues because they often overlook individual differences in general, and haven't been trained to see the basic-psychology payoffs to considering normal and extreme variations in intelligence, personality, etc. This oversight is reinforced by the tendency of clinicians to promote categorical rather than dimensional views of mental illness, which make basic researchers think of exotic "schizophrenics" rather than ordinary "schizotypy," "the brain-damaged" rather than "the g factor," or "psychopaths" rather than "aggressiveness."

Mental illness and normal human variation is especially invisible to psychology researchers in highly selective universities, which screen out almost everyone except high-intelligence, emotionally-stable, benignly-compulsive students. Lastly, researchers have the partly mistaken view that the pharmaceutical industry is making enormous progress in medicating mental illness out of existence, and that we have nothing to contribute to the juggernaut of molecular neuropsychiatry.

To address these problems, I offer some suggestions for ways that APS could improve the salience of mental illness in basic research. APS could form stronger political alliances with evidence-based clinical psychology movements, such as the Academy of Psychological Clinical Science, which is having a hard time making much impact in APA. If APS "owned" evidence-based clinical research and practice a little more openly, we'd be in a better position to promote successful relations between basic psychology and clinical science in Washington and at the National Institutes of Health.

APS could also promote National Science Foundation and NIH funding opportunities that use clinical research methods and populations to inform basic research, rather than just promising that basic research will someday help cure mental illnesses. Many basic psychology researchers don't have much interest in mental illness, but they might pay attention to it if it were easier to get funding to study psychopathologies as windows onto normal cognition, emotion, or motivation, among others. These funding opportunities could include graduate fellowships, post-docs, mid-career training grants, or conference grants.

On a smaller scale, APS could invite some bright clinicians to write pieces for the Observer about "basic research questions that clinical folks want APS to answer," or about their own personal experiences of seeing mental illness among their family, friends, and colleagues, and searching their souls about how their research is or isn't relevant.

One last suggestion is to take a poll of APS Members about their own mental illness symptoms and syndromes, and publish the results in the Observer, to remind ourselves just how common many of these problems are even among our apparently "normal" colleagues.

- Geoffrey Miller
University of New Mexico

Levenson Responds:

MY THANKS TO WEGNER AND Miller for contributing to this important dialogue and nicely framing two different sides of this issue. Wegner's piece eloquently makes the case for the value of studying basic psychological processes in normal, non-disordered populations and Miller's piece powerfully makes the case for venturing out to study both normal and disordered populations. Finding the right balance between basic behavioral and social science research using normal populations and patient/disorder-oriented research is one of the most important challenges facing psychological science, NIMH, and the other NIH institutes. A misstep at this juncture will have far-reaching scientific and health consequences. I hope others will join in on this dialogue.

Biased Observer?

CONSIDERING THAT THE American presidential election is so close (and may be over by the time this letter is published), I was surprised to read the article "Fatal Attraction" [Observer, October 2004], which was obviously pro-Kerry and anti-Bush. I note also the lavish presentation of a claim that is already in press as an empirical article in Psychological Science. Included in that presentation are advertisements both of the in-press article, as well as of a book written by the authors.

Sheldon Solomon and his co-authors (Jeff Greenberg and Tom Pyszczynski) seem to suggest that, in the fight against organizations that have perpetrated acts such as 9/11, "triumphing over evil" is a "non-rational" concept, a strategic use of fear; and that if Bush wins on the basis of such "non-rational terror management," the outcome would be antithetical to democracy, even "totalitarian." The message is that anyone who votes for Bush rather than Kerry is, as they put it, "thinking with their hearts" rather than "with their heads."

Missing, however, from both the reference list and the contents of the article, is any acknowledgement of opinions that are contrary to this take-home message.

Among those contrary opinions are those held by people for whom terms like "axis of evil" are meaningful descriptors that can be rationally justified. People who hold these contrary opinions think ("with their heads") of historical examples like the dispute in May 1940 in England, when that country stood alone against the Hitler's totalitarian regime. Lord Halifax and his followers, who viewed themselves as using their "heads," wanted to negotiate with Hitler. Churchill, presumably "cultivating the culture of fear" (as the authors aver that Bush is doing), wanted to destroy Hitler's "evil empire." Luckily for the cause of freedom, Churchill won that particular argument, using both his head and his heart.

The Observer, as an important representative of the science of psychology, is supposed to be concerned with the disinterested study of the discipline. I think it was mistaken both in the timing and the publication of such a one-sided, partisan, and inherently political, piece.

- John Furendy
University of Toronto

The Authors Respond:

IN OUR OCTOBER 2004 OBSERVER article "Fatal Attraction" we discussed findings demonstrating that reminders of death or the events of 9/11 increased Americans' preference for charismatic leaders in general and President George W. Bush in particular. We did not argue that the allure of triumphing over evil, or voting for Bush, is necessarily a result of non-rational defensive processes. Rather, we argued that the fact that reminders of mortality amplify these preferences implies that political predilections are influenced by such processes.

Whereas it might be argued that increased support for Bush and his policies in response to reminders of 9/11 reflects a rational conclusion based on beliefs about who would better protect us from future attacks, one would be hard-pressed to interpret the finding that reminders of the general problem of death produce a similar effect in this fashion. Based on the substantial existing body of research on the processes through which thoughts of death affect judgment and behavior, it seems clear that mortality salience effects do not result from rational cogitation. In fact, published research has shown that instructing participants to think rationally reduces the effects of reminders of mortality.

We respectfully disagree that our piece was one-sided and partisan and therefore inappropriate for "the science of psychology," and quote from our article so readers can judge for themselves:

"How should these findings be interpreted? With some degree of caution. ... We ... do not mean to imply that all support for President Bush is necessarily a defensive reaction to concerns about death. And although it is a matter of public record that President Bush's re-election campaign has been carefully crafted to emphasize the war on terrorism and domestic security, the strategic use of fear to advance political agendas has a long history in American politics ... and is by no means confined to the Republican Party."

Finally, we don't believe that Churchill's stand against Hitler's Nazi regime is in any way comparable to President Bush's use of fear to rally support for the invasion of Iraq, but perhaps that is a question best left for future historians to debate. In contrast, the question of whether thoughts of 9/11 and fear of death influence support for charismatic leaders in general and President Bush in particular can be and has been assessed by scientific research; we encourage other psychologists to evaluate the scientific merits of such research based on additional research and reasoned argument, rather than claims of political bias. That's how science progresses.

- -Sheldon Solomon, Jeff Greenberg, and Tom Pyszczynski

Out of Cite

CONGRATULATIONS TO RODDY Roediger for his article "Great Dissertations" [Observer, October 2004]. However, I want to point out a methodological shortcoming from using the electronic version of the Institute of Scientific Information Web of Knowledge. This tool represents citations beginning only in 1981. To get an accurate count of papers published before 1981, one must count the citations in the bound paper volumes. So, adding in these citations provides a corrected count for Roediger's 1973 dissertation article - and my own from 1976 - above the threshold of 100. Adding in the pre-1981 citations will also enormously increase the counts of many of the eminent people who made the cut in Roediger's essay using only post-1981 criteria, including Henry Kaiser, with 1,986 post-1981 citations for his 1958 article, Jane Loevinger with 397 citations for her 1957 dissertation article, and E. L. Thorndike with 306 for his 1898 paper. Perhaps the threshold will have to be raised to 200 citations, as Roediger suggested, or adjusted for date of publication, so that rate of publication should matter.

One may hope that eventually the ISI Web of Knowledge database will be extended even further into the past than it is at present. There is a 10-year accumulation from 1945-54 for the Science Citation Index and from 1956-1965 for the Social Science Citation Index. However, citations of famous papers before that time, such as Thorndike's, would still be undercounted. Of course, the considerations discussed in the letter do not apply to dissertations (or any other papers) published in or after 1981. The electronic Web of Knowledge is accurate for those articles.

- J. Philippe Rushton

University of Western Ontario