Date: Fri, 16 Jun 1995 04:10:15 -0700 To: Multiple recipients of list MADNESS ---------- Forwarded message ---------- Date: Wed, 14 Jun 1995 21:24:40 CST From: csheridan@CCTR.UMKC.EDU To: fordycej@halcyon.com Care and Objectivity in the Treatment of the Sexually Abused Patient Paper Presented at the Annual Convention of the Missouri Psychological Association, April 1993, Kansas City Charles L. Sheridan University of Missouri-Kansas City I have always been impressed by the willingness of psychologists, even those on modest incomes, to invest their time, energy, and money in strengthening their therapeutic skills. Though we often disagree with each other on technique, most of us show that we care about our patients, and want to give them the best service available. Unfortunately, the science of psychology often fails to provide an applicable foundation for our practice, and we have to turn to other sources to find a ground for our methods of helping. Psychology as a discipline has only taught us to look for our foundations in science. All of us, in our training, had to take courses in scientific methodologies, so we are pretty good at identifying good and bad research. But we often have to sever our ties to scientific method in order to find answers to the pressing questions of clinical practice. But once we break that connection to science, we have no special skills in discriminating good from bad methods. Nothing in our psychological training makes us especially good, discriminating scholars. So we end up basing our professional work on whatever wisdom we have amassed from our life experience. At that point, we are no better than the old Roman Stoics who used a similar methodology, and resembled psychologists in that they used to guide people on how to live, and did so on a fee-for-service basis. Each of them had a personal view of how to live well, and each drew a certain group of people to whom their ideas appealed. Their systems lacked the qualities of reliability, validity and generalizabiliity we expect from approaches based in science. Naturally, a person using this kind of method has a strong emotional connection to the personal system, as do those who naturally gravitate to it. So it tends to be comfortable and marketable. Unfortunately, when we psychologists shift to such an approach, we are subject to all the risks and errors that plagued pre-scientific treatments throughout history. My favorite example is the case of lancing and blood-letting. These were practices based on the old theory of humors, which attributed disease to imbalances of substances in the body. Bleeding was thought to restore the balance and thus to heal. The formation of pus was deemed a good sign of the body's release of vile humors, and so a cut that did not yield pus was dealt with by lancing (with dirty blades) that made the pus form. Today we would say the purported healers were actually creating infections. These same healers would also drain large quantities of the blood from patients. During the Bubonic Plague the volume of human blood was not known, and thought to be much greater than it is. So the "healers" were actualy depleting the blood supply of their already sick patients, and, no doubt, killing them. It is striking that the lethality of bleeding and lancing was not recognized until controlled experiments were done, for example by the surgeon and anatomist, John Hunter. Please realize that the doctors who were killing their patients were no dumber than we are, and their senses were as acute as ours. In fact, if they were here today they would probably be outstanding people. Yet, they could not see that they were doing harm. The only thing that sets a modern psychologist apart from these historical predecessors is better methodology. When we abandon that special methodology, we are may well find ourselves doing harm to our patients when we mean to treat them with care. Psychologists today are increasingly undermining the basis for their special authority. Starr in his classic book The Social Transformation of American Medicine does an interesting analysis of professional authority. He points out that the authority of the State is based on the right to use force, but professionals have to base their authority on access to a special body of knowledge that is known to be reliable and valid and therefore compels assent. Psychology has always used science as the source of that special knowledge. Applied psychologists have been forced to walk a thin line between common sense and intuition, on the one hand, and scientific information on the other. They are supposed to be "scientist-practitioners", difficult though that may be. In recent times more and more of them seem to have stepped over the line and cut off their ties to science entirely. But this profoundly undermines any claims they had to professional authority. I am not saying they have to go back to the natural science model of psychology, but that they MUST find SOME solid basis for their professional authority. What I see happening is that people get their degrees in academic institutions that require scientific training, but after graduating feel that their degree has anointed them so whatever judgments they make are somehow authoritative. So we regularly see psychologists pontificating before the press about matters neither they nor anyone else really has any professional knowledge about. I think they see no harm in this, but it undermines the authority of psychology as a profession. Part of the fault lies with research psychologists. Their work often has more value in advancing their careers than in advancing useful knowledge. I notice that Fats Goldberg is a special speaker at this convention. That tells us a lot about how much we value the research on obesity done by scientific psychologists. When we really want to know how to lose weight we call upon someone who has lost weight and kept it off for a while. Selecting such a speaker to address the State professional organization is a kind of institutional Freudian slip in that it inadvertently reveals how little reliance we place on the science that supposedly justifies our professional specialness. I want to emphasize again that this is not one of those academician's speeches warning of the importance of returning to our roots in the natural science model of psychology. I see both strengths and limitations to the scientific method applied to human matters. My point is not that we necessarily have to return to that model, but that we have to find some kind of model that legitimizes our professional authority and therefore provides us with a clear professional identity. Law doesn't base its authority in natural science, but imagine a lawyer who tries to operate by just deciding what he or she personally views as right and just! That is very much like what many psychologists are leaning toward today. We might be able to establish a good foundation for psychology in the human, instead of the natural sciences. Wilhelm Dilthey advocated a sharp distinction between human and natural sciences, and looked to such fields as history to augment measurements of human behavior. It might well do to look to history, anthropology, political science, and law for our foundations. What will NOT do is to abandon science and replace it with fads and cults. Remember, science is a method for catching ourselves in errors, and it took thousands of years to develop, so we have quite a task before us if we decide to replace it with something else. Despite its limitations when applied to human things, science has some significant strengths. It is very good at catching false alarms (i.e. keeping us from believing something to be true when it isn't). So science helped us to see that bloodletting was not a good cure. If we are going to leave science behind, we have to find something else to control our false alarm rate. Science enables us to distinguish between good and bad theories. One of the basic principles of science is that theories be "falsifiable". This means that some kind of test can lead us to be skeptical of our theory, and eventually even abandon it. A theory that is not in some way falsifiable is not scientific, and one might even be tempted to say, irresponsible. It is very doubtful that many of the most popular fad theories being used today are falsifiable. Often they say that trauma X will have result Y, but if Y does not occur, they say the person is covering up the symptoms through some device like denial. We need some basis for separating the good theories from the bad ones, and this requires theories that have clearer implications. Another thing that science does is to help us break through our illusions. Before Stanley Milgram did his experiments on obedience to authority, most of us thought that the holocaust had to be based on some basic flaw in the national character of Germans. OUR people would never do such thing. But Milgram provided dramatic evidence that they very likely WOULD do such a thing. Without the scientific model, it would have been much harder to break through the illusion. We need something to protect us from our illusions, lest we do harm when we intend to help. My concern that many present day therapists might be doing more harm than good probably started when there seemed to be a sudden outbreak of multiple personality disorder. I had been interested in this topic for many years, had done over a decade of research on dissociations produced by brain modifications as well as in the intact brain, and was aware that all the way back in the 19th century Janet had pointed out how easy it was to induce multiple personalities by showing a lot of interest in them and by giving them names. There is even a much older body of knowledge about a very similar, perhaps even the same, phenomenon- that of opening oneself to the influence of alien spirits, but a real discussion of that might be out of place here. Suffice it to say that passivity and openness in the context of a belief system that expects such things can indeed produce them. For example, the anthropologist, Wade Davis, studied methods of producing Zombies, their existence having been verified by the reappearance of people for whom there were reliable death records. He found that a chemical called tetrodotoxin made it possible for them to seem dead enough to fool a good doctor, but that the induction of Zombie-ism had to do with their belief system and the occurrence of certain culturally accepted rituals. A therapist working in the context of some of the present day systems can easily produce a very wide range of symptoms, no doubt including multiple personality. When we deal with people in crisis, in what has been called a "teachable moment", and we initiate them into our belief system, often in the context of other, already initiated believers, we can get them to do and believe just about anything. Religious cult conversions show this very clearly. The use of hypnosis to draw out alternate personalities is alarming. We know very well that hypnosis in such contexts can provoke remarkable, iatrogenic phenomena, as you will see when I discuss the work of Charcot. One of the problems with modern therapists is that they often have not really learned the history of psychology and so are making the same mistakes our predecessors made. In the 19th Century, it was believed that the right brain was a kind of beastly Mr Hyde, while the left was a genteel Dr. Jekyll. All of this blended with such things as the discovery of Neanderthalers in the middle of the 19th Century, and with a whole colonialist ideology, nicely ripped apart by Steven J. Gould in his book The Mismeasure of Man. This broader cultural context influenced the reactions of patients, but investigators of the day thought they were observing fundamental psycho-physiological phenomena. Multiple personalities in those days conformed to the prevalent belief system of the investigators. They would have paralyses of the right hand (left hemisphere) when they manifest a socially inappropriate personality. Supposedly only the right brain was controlling them at the time, and this was the "Neanderthaler", Mr. Hyde side. In contrast, they would show genteel behavior while having paralysis of the left side of the body. Anne Harrington in her book Medicine, Mind and the Double Brain points out that Charcot hypnotized people by way of one eye on the assumption that this would selectively influence the brain half on the opposite side. By so doing, he could get patients to display dramatically different personalities, moods, etc. on only one side of the brain. Charcot was considered the greatest neurologist of the 19th Century up till his death. Freud went to study with him and came back to Vienna inspired. Because of his stature as a scientists, I would be inclined to think maybe he had discovered some lost bit of knowledge here except for the fact that we now know that each eye feeds into BOTH brain halves. The only reason these patients were showing this strange behavior was because it was what Charcot expected. Sadly, after Charcot's death it became eminently clear that many clinical manifestations he had become noted for were in fact iatrogenic. And Charcot's methods were amazingly consonant with those used by many therapists today. I could recount many other historical examples of iatrogenic reactions. For example, Mesmer induced dramatic psycho- physiological crises through various procedures devised on the analogy of magnetism. Later, Puysegur, who expected different results, used mesmeric methods, but got somnambulism. There is not time to review the full range of historical examples, but they make it clear that therapists can get patients to dance to just about any tune. Patients can be induced to devote much of their life to exemplifying the theories of their therapists. So I am alarmed at the ad hoc methodologies being used by many therapists today, and I am alarmed at therapists' obliviousness to how powerfully they can influence their patients and get them to devote their lives to being just the kind of victim that particular therapist expects. It is sad that this can happen to very caring therapists. The only solution is to temper their care with objectivity.