Cognitive Behavior Therapy (CBT) has become "THE" evidenced-based psychotherapy. The National Association of Cognitive-Behavioral Therapists explains what that means.

Cognitive-behavioral therapy is the most researched psychotherapeutic approach because:

• each cognitive-behavioral approach has specific techniques that can be tested for effectiveness;
• CBT encourages the development of specific goals that are measurable, and, therefore, can be researched;
• cognitive-behavioral therapists (to varying degrees) are interested in the research and research process;
• cognitive-behavioral therapists are not interested in techniques that "feel right" or "seem correct", but techniques that are effective.

If that were all true, then there would be no issue, everyone would start doing CBT. Here is a great post from Anxiety Insights.

It is hailed as a quick fix for depression, schizophrenia, ME - even infertility. Now the government sees it as the answer to Britain's widespread mental health problem. So what is cognitive behavioural therapy? And does it really work?

There is no doubt that CBT has the weight of scientific evidence behind it when compared with other forms of psychotherapy, such as the let-them-talk-freely ideas of Rogerian counseling or psychodynamic therapy, which tend to be much harder to subject to clinical trials because of their more nebulous nature.

But while there are few, if any, mental health specialists prepared to dismiss CBT out of hand, there are a significant number of experts who feel that CBT is being grossly oversold. The primary objection seems to be that it doesn't work for everybody (not even nearly, say some), and that this one-size-fits-all approach may ride roughshod over more traditional forms of therapy which can be just as - if not more -worthwhile in many cases.

Ok, so what is all the controversy? CBT can be considered an ideology of treatment, or it can be seen as a structure within which all therapy functions. In a way, most therapists providing time-limited psychotherapy under standards set by insurance companies are providing CBT under a broad definition. Insurance companies require therapists to help the client set goals in an Individual treatment plan that are measurable. In other words, someone other than the therapist and the client can see the goal has been accomplished. You might ask, "how can I see that I'm feeling better?" Well, you may smile more. You may report you are feeling better, i.e. the symptoms you presented to the therapist when you agreed to therapy have improved.

Ultimately, in my experience, most of the time, both clients and therapists hope that the clients behavior will change. When asking them after the fact, both will agree at least part of what they were working on was changing the thoughts the client had about their situation in hopes that would improve their feelings and behavior.

These two criteria, measurable goals, and a focus on behavior change, describe a broad definition of "CBT" authorized for payment by insurance companies.

The National Association of Cognitive-Behavioral Therapists defines CBT much more narrowly. Let's go through their definition, point by point.

What is Cognitive-Behavioral Therapy? [Also here.]

Cognitive-Behavioral Therapy is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do. Cognitive-behavioral therapist teach that when our brains are healthy, it is our thinking that causes us to feel and act the way we do. Therefore, if we are experiencing unwanted feelings and behaviors, it is important to identify the thinking that is causing the feelings / behaviors and to learn how to replace this thinking with thoughts that lead to more desirable reactions.

There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy.

However, most cognitive-behavioral therapies have the following characteristics: 1. CBT is based on the Cognitive Model of Emotional Response. Cognitive-behavioral therapy is based on the scientific fact that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change.

Well, that sounds reasonable, but a bit contrary to common beliefs. If changing our thoughts change our feelings and behavior, we ought to be able to memorize new beliefs and we're done! Anyone who has tried to make a New Year's resolution or quit cigarettes know that it's just not that simple.

2. CBT is Briefer and Time-Limited. Cognitive-behavioral therapy is considered among the "fastest" in terms of results obtained. The average number of sessions clients receive (across all types of problems) is only 16. Other forms of therapy, like psychoanalysis, can take years. What enables CBT to be briefer is its highly instructional nature and the fact that it makes use of homework assignments.

I know from my stint in Clinical management, that average number of sessions for most therapists in places I worked varied from 5 to 10. Only a few of therapists I worked with would call themselves practitioners of CBT. Sixteen is probably a good number of sessions when a client should expect to have experienced significant improvement. If not, they need to consider seeing another therapist or at least a major change in the treatment plan.

My therapeutic experience suggests that many if not most of the most needy clients don't have the where-with-all to complete a homework assignment without taking the time to educate and redirect motivation for several sessions.

3. A sound therapeutic relationship is necessary for effective therapy, but not the focus. Some forms of therapy assume that the main reason people get better in therapy is because of the positive relationship between the therapist and client. Cognitive-behavioral therapists believe it is important to have a good, trusting relationship, but that is not enough. CBT therapists believe that the clients change when they learn to think differently; therefore, CBT therapists focus on teaching rational self-counseling skills.

Now this assumption seems to match common sense. Of course, one would expect the working relationship with the therapist to be important, but not the primary reason therapy works. The problem is that research suggests it's not that simple. In a previous post I briefly mentioned a concept called the attention placebo. The placebo is essentially the part of the therapeutic situation that is not the treatment being measured. Think about that. Everything about the therapy is intended to be helpful. How can you separated one part from another? Common sense, again, is correct. It's not easy and deceptively complex.

Rehm in the American Psychological Association Journal Prevention & Treatment. 5(1), July 2002, described the attention placebo as life events, social support, hopeful expectations, and biochemical changes that accompany treatment and enhance immune function and biochemical balances that facilitate recovery. Research has generally demonstrated that the attention placebo has a substantial therapeutic effect. In an article written by Michael Lambert in JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 61(7), 855–869 (2005), he states,

Evidence is presented demonstrating that placebo control groups benefit more from psychotherapy than no-treatment control groups but less than patients who receive theory-driven treatments.

In my previous post, my point was slightly different.

While I understand the argument that without a placebo control, one can never hope to measure the effect of treatment attributable to medication alone. However, imagine if a patient picked up his medication from a grumpy, shaming pharmacist, do you think the medication would be as effective? I think not. The placebo effect is as integral a part of treatment as the medication.

All indications are that the relationship with the therapist, whose personality is as unique as you or I, is inseparable from the particular therapy provided. The methods used even in CBT are inseparable from the personality and style of the therapist.

Lets get back to the definition of CBT.

4. CBT is a collaborative effort between the therapist and the client. Cognitive-behavioral therapists seek to learn what their clients want out of life (their goals) and then help their clients achieve those goals. The therapist's role is to listen, teach, and encourage, while the client's roles is to express concerns, learn, and implement that learning.

With the exception of one choice of word, I think most therapists would agree with this statement. Helping a client to work on "what they want out of life" is a sure way to extend therapy from 16 sessions towards the years that psychoanalysis often requires. Lets settle on the phrase in parentheses, "their goals". Items 6, 8, 9 and 10 are essentially non-controversial and enjoy a near universal application in various therapeutic ideologies.

5. CBT is based on stoic philosophy. Cognitive-behavioral therapy does not tell people how they should feel. However, most people seeking therapy do not want to feel they way they do. CBT teaches the benefits of feeling, at worst, calm when confronted with undesirable situations. It also emphasizes the fact that we have our undesirable situations whether we are upset about them or not. If we are upset about our problems, we have two problems -- the problem, and our upset about it. Most sane people want to have the fewest number of problems possible.

Again, the definition seems to fly in the face of common sense, and also contradicts item 4 in the definition. In my experience, people come to therapy feeling miserable. People who are stoic, out of touch with their feelings, may not even have a good idea why they are miserable. Their primary goal is to feel better. A CBT therapist claims to have ready a redefinition of the client's primary goal. Recall item 1 in the definition and my response. Thoughts are suppose to have total control over our feelings and behavior. The fact is that, from a physiological point of view, there are many kinds of thoughts and feelings, only some of which are directly available to us at anyone one moment. Behavior is controlled by a bio-chemical process we are only beginning to understand in a very rudimentary way.

Westen in his article in journal Psychological Bulletin November 1998 Vol. 124, No. 3, 333-371 published by the American Psychological Association, makes a spirited and thorough explication of how unconscious thoughts and feelings affect our behavior every day, with little or no direct access to immediate change as suggested by CBT. I'll only give one example of the research cited in his lengthy literature review.

Shedler, Mayman, and Manis (1993) studied participants in two studies with illusory mental health, who reported themselves to be free of psychological distress and symptomatology but whose descriptions of their early memories (a projective measure) were rated as showing signs of psychological disturbance. Participants underwent a mildly stressful procedure that can be disturbing to someone who is highly defensive (reading aloud, performing a phrase association test, or providing projective stories). Those participants who viewed themselves as healthy but showed unconscious evidence of distress in their early memories were significantly more reactive on a measure of cardiac reactivity related to heart disease than participants who were either low or high on both measures of distress. They also showed more indirect signs of anxiety (such as stammering, sighing, and avoiding the content of the stimulus) while simultaneously declaring themselves to be the least anxious during these tasks.

Goleman in his book Emotional Intelligence (1995, Bantam Books, New York) says:

Unconscious opinions are emotional memories and are stored in the amygdala. The dry facts of the emotional memory are stored in the hippocampus. The amygdala stimulates the adrenal gland to ensure an intense response to the memory. The more intense the stimulation, the stronger the imprint.

During at least the first year or two of life, this is the primary memory function. These early memories become the rough blueprints for future emotional life.

Goleman does a good job of citing the literature supporting his assertion. Clearly our conscious thoughts do not control all feelings and behavior. Nor will changing our conscious thoughts always change our feelings and behavior.

Item seven is the last I will comment on.

7. CBT is structured and directive. Cognitive-behavioral therapists have a specific agenda for each session. Specific techniques / concepts are taught during each session. CBT focuses on helping the client achieve the goals they have set. CBT is directive in that respect. However, CBT therapists do not tell their clients what to do -- rather, they teach their clients how to do.

This item and it's reliance on homework makes it pretty clear that CBT was designed to treat relatively healthy individuals with only a couple problems that need addressing for which the client willingly cooperates with working on one goal at a time. In my experience, most of the clients I've seen have chaotic lives. I can't count on planning an agenda for a session. While I may bring a list of items I'd like to cover, I check in with the client first and usually find our time directed to a new incident in the past week or so.

CBT is clearly not the new "Coca Cola". It does provide a good broad structure to conceive of therapy with measurable goals, stepwise progress and thoughts, feelings and behavior change as preferred outcomes. In that sense, it makes all such therapy "evidence-based."

Recently, a post at Anxiety and Depression Treatments Blog got my attention. It refers to a BBC NEWS article titled "Paranoia 'a widespread problem". The article is about a survey done in the UK by the Institute of Psychiatry at King's College London. The blog characterized the results as laughably high. Here is an excerpt from the BBC article.

One in three people in the UK regularly suffers paranoid or suspicious fears, clinical psychologists have found. A team at the Institute of Psychiatry at King's College London interviewed 1,200 people about whether they had thoughts about others doing them harm. They found levels of paranoia were much higher than previously suspected - and almost as high as those for depression and anxiety. The researchers say paranoia can cause real distress.

The study found that:

• Over 40% of people regularly worry that negative comments are being made about them
• 27% think that people deliberately try to irritate them
• 20% worry about being observed or followed
• 10% think that someone has it in for them
• 5% worry that there is a conspiracy to harm them

The article seems to imply up to 50% of those surveyed reported paranoid thinking. Without a context, indeed the bullet points above seem to say just that. I went to the Institute of Psychiatry at King's College London website and found a link to the article.

The study was based on an anonymous Internet survey of students at King’s College London, the University of East Anglia and University College London invited by e-mail to participate in a survey of ‘everyday worries about others’. The web based survey method was considered by the authors "to provide a safe environment for
survey participants to disclose suspicious thoughts. Internet research has been found to reach the same conclusions as laboratory-based studies (Birnbaum, 2001)." However, this method would very likely create conditions where an exaggerated response might be expected.

[The authors concede that] people who self-select for questionnaires of this type may be more prone to psychological disturbance, or the stigma of appearing so might skew the sample in the opposite direction. Thus, our investigation in a selected group indicates a need for more elaborate and more truly epidemiological studies.

One of instruments in use was included in tables with the resulting responses. So I responded to the survey honestly. Given my work, I meet a larger proportion of people with personality disorders who maybe worthy of suspicion than perhaps the average person might contact on a day to day basis. I remember the experience I had as an adolescent and college student where I was exposed to a disproportionate number of rebellious young people. I had every reason to be suspicious of many of my peers, so I suspect my current contacts through my practice might represent an experience in college in the upper third of peer stress. Indeed two-thirds of the respondents were women, perhaps more likely to experience the stress of peer pressure. Interestingly, the responses between men and women in the survey were reported to be not significantly different.

It is apparent in going through the Paranoia Checklist, that I experience a lot of suspicion in my life, but not as much stress about it as one might expect from a college student among peers. The authors had a similar concern.

There are also issues concerning whether the experiences assessed are actually unfounded; questionnaire studies may include an unknown proportion of paranoia that is realistic and therefore well judged and appropriate. It is also unknown whether any of the participants had received treatment for a psychiatric disorder, and what the level of substance use was in the group.

So the authors appropriately review all the possible problems with the survey, Their bullet points are clear and not misleading listing the limitations.

CLINICAL IMPLICATIONS

• Having suspicious thoughts is a common experience and provision of this information may help reduce patient distress.
• Feelings of hopelessness and lack of control may contribute to the occurrence of more suspicious thoughts, whereas gaining distance from such thoughts and evaluating them may reduce such experiences.
• Not talking to others about suspicious thoughts, feeling vulnerable and behaving timidly with others may be factors in the development of paranoia.

LIMITATIONS

• An epistemologically representative sample was not recruited.
• The group mainly comprised young adults have higher rates of suspiciousness.
• Only cross-sectional associations between paranoia, coping strategies and social^ cognitive processes were examined.

The BBC article really does a poor job of conveying the information of the study. The reporter seemed to have latched onto the stigmatizing word paranoia and grabbed at statistics that sensationalized rather than communicated accurately the results of the study. In fact, there was some very interesting results that a worth considering in the context of the limitations of the study.

In the press release announcing the study to the public, the agency does a nice job of summarizing the results. The study I can fault at only one point. The authors began using the word paranoia in the discussion to refer to at least the upper end of the hierarchy of suspicious thoughts.

Approximately 10–20% of the survey respondents held paranoid ideation with strong conviction and significant distress. [...] If paranoia is an everyday phenomenon, which many people manage well, then it provides an opportunity to gain clinically useful information on optimal ways of coping.

Substitute the phrase "suspicious thoughts" for paranoia and the miscommunication goes away. The press grabbed the word "paranoia", guaranteed to grab attention with a catchy headline, as reflecting the primary focus of the research which was in fact focused on suspicious thoughts. With the ready access of research to the general public via the Internet, authors need to be aware of the potential misunderstandings of lay persons reading their articles.

MentalHealthCare.org.uk

The results indicate that suspicious thoughts are a weekly experience for many people. For example, 30-40% of participants had ideas that negative comments were being circulated about them. 10-20% of those who took part in the survey had paranoid thoughts that they firmly believed and which caused them significant distress. This suggests that there is a significant group of people in the population who suffer distress as a result of paranoid thoughts but do not seek treatment from mental health services.

The authors believe that this may be because many people feel uncomfortable talking about suspicious thoughts and fear being thought of as ‘paranoid’, a term which has stigma attached to it.

According to the survey people with frequent and distressing paranoid thoughts tend to deal with them by isolating themselves, giving up activities and feeling powerless or depressed. These so called coping strategies have been shown to be less effective than other strategies in reducing the distress caused by such thoughts.

People with less severe paranoid thoughts, however, tended to cope with their suspicious thoughts by keeping things in proportion (known as ‘not catastrophizing’), and by keeping enough distance from their thoughts to see them in an unemotional way. These techniques have been shown to be more effective than those used by people with more severe paranoid thoughts. It is not clear from this survey whether using a less effective coping method causes more paranoid thoughts or whether the paranoid thoughts make people more likely to use less effective coping methods.

The authors also found evidence that not talking to other people about suspicious and paranoid ideas can lead to a greater number of such thoughts. In addition people with low self-confidence are more likely to suffer suspicious and paranoid thoughts. The researchers believe that low self-confidence can produce feelings of being vulnerable to some form of attack and so lead to feelings of suspicion.

The researchers call for treatments for paranoia to take into account the findings of this survey. Firstly mental health professionals should accept that paranoia is a very common experience. Secondly people dealing with paranoid thoughts should be encouraged to talk about their experiences. Efforts should be made to improve the self-esteem of people with paranoid ideas, and they should be encouraged to feel in control of their situation. All of these techniques are used in Cognitive Behavioural Therapy, a psychological treatment that is increasingly being used to treat psychosis and schizophrenia, conditions that often involve paranoid thoughts.

Perhaps the most significant result of the study was initial suggestions in the data that suspiciousness belongs to a continuum including paranoia.

Our survey clearly indicates that suspicious thoughts are a weekly occurrence for many people: 30–40% of the respondents had ideas that negative comments were being circulated about them and 10–30% had persecutory thoughts, with thoughts of mild threat (e.g. ‘People deliberately try to irritate me’) being more common than severe threat (e.g. ‘Someone has it in for me’). In contrast, only a small proportion (approximately 5%) of respondents endorsed the checklist items that were the most improbable (e.g. that there was a conspiracy).

Nevertheless, the rarer and odder suspicions – characteristic of clinical presentations – occurred in tandem with the more common and plausible experiences. The rarer the thought, then the higher the total score indicated by its presence. There has been no previous examination of paranoia in this way. The findings indicate a hierarchy of paranoia [see diagram]: the most common type of suspiciousness is that of a social anxiety or interpersonal worry theme; ideas of reference build upon these sensitivities; persecutory thoughts are closely associated with the attributions of significance; as the severity of the threatened harm increases, the less common the thought; and suspiciousness involving severe harm and organisations and conspiracy is at the top of the hierarchy.

The implication is that severe paranoia may build upon common emotional concerns, consistent with a recent cognitive model of persecutory delusions (Freeman et al, 2002; Freeman & Garety, 2004). The interesting questions therefore concern the identification of the additional factors that contribute to the development of severe paranoia and whether there are qualitative shifts in experience at the top end of the hierarchy (note that individuals at the higher end of the hierarchy tended to endorse all their suspicious thoughts with high levels of conviction and distress). The survey findings also indicate that there is a continuous (exponential) distribution of total number of suspicious thoughts in the general population, although the thoughts appear in a hierarchical arrangement. No distinct subpopulation was identified. This therefore demonstrates correspondence to common mental health disorders such as depression and anxiety.

It's apparent similarity to depression is not a surprise. It has always struck me that depressive and paranoid thinking are special cases for obsessions based on the thematic content of the thought. This confirmation continues the cry for a medication focused on relieving the the compelling nature of obsessive thinking of all kinds. The driving repetition of the thought may have a major responsibility for danger to self and others. Repetitive themes of shame may well lead to suicide ideation and attempts. Obsessive thinking regarding persecution involving a particular person seems related foretell vengeful think and ultimately homicidal ideation and attempts. More traditional obsessive thinking is thematically focused on safety in the form of checking to confirm no hazard and compulsive cleaning to prevent exposure to germs. It makes less sense to me to separate diagnoses based on thematic content than structure and pattern of symptoms. Not surprisingly, Anafranil and the SSRIs have had notable success with obsessive symptoms and depression. I've only seen a few examples of paranoid thoughts treated by SSRIs, all as I recall were relatively successful. It would seem a more targeted medication related to repetitive thought patterns would be more fruitful in treating the obsessive symptom.

Freeman, D., Garety, P.A., Bebbington, P.E., Smith, B., Rollinson, R., Fowler, D., Kuipers, E., Ray, K., Dunn, G. (2005). Psychological investigation of the structure of paranoia in a non-clinical population. British Journal of Psychiatry, 186(5), 427-435.

In keeping with my previous article about isolation, this quote is from Markham's Behavioral Health.

It is your fear that makes you a slave - it is your fear. When you are fearless you are no longer a slave; in fact, it is your fear that forces you to make others slaves before they can try to make a slave out of you.

-Osho

King Crimson | 21st Century Schizoid Man Lyrics

Cats foot iron claw
Neuro-surgeons scream for more
At paranoias poison door.
Twenty first century schizoid man.

Blood rack barbed wire
Polititians funeral pyre
Innocents raped with napalm fire
Twenty first century schizoid man.

Death seed blind mans greed
Poets starving children bleed
Nothing hes got he really needs
Twenty first century schizoid man.

When I first heard of the study excerpted below, I immediately thought of King Crimson's screeching discordant guitar accompanying Greg Lake (more famous for his part in Emerson, Lake and Palmer) singing in angry, alienated tones about the coming 21st century when isolation and alienation will be pandemic. I had found that song disturbing and eventually difficult to listen to. Thus the LP has gathered dust ever since.

Miller McPherson et al from University of Arizona and Duke University wrote an article in AMERICAN SOCIOLOGICAL REVIEW, 2006, VOL. 71 (June:353-375) titled
"Social Isolation in America: Changes in Core Discussion Networks over Two Decades". This 2004 study replicated a 1985 survey using the General Social Survey (GSS) of about 1500 people drawn from a nationally representative sample. What they found stunned them.

The number of people who have someone to talk to about matters that are important to them has declined dramatically, and the number of alternative discussion partners has shrunk. In his groundbreaking study of social networks, "To Dwell among Friends", Claude Fischer (1982:125-27) labeled those who had only one or no discussion ties with whom to discuss personal matters as having marginal or inadequate counseling [close social, not professional] support. By those criteria, we have gone from a quarter of the American population being isolated from counseling support to almost half of the population falling into that category.

The American population has lost discussion partners from both kin and outside the family. The largest losses, however, have come from the ties that bind us to community and neighborhood. The general image is one of an already densely connected, close, homogeneous set of ties slowly closing in on itself, becoming smaller, more tightly interconnected, more focused on the very strong bonds of the nuclear family (spouses, partners, and parents). The education level at which one is more connected through core discussion ties to the larger community than to family members has shifted up into the graduate degrees, a level of education attained by only a tiny minority of the population. High school graduates and those with some college are now in a very family-dominated social environment of core confidants.

[...]Having a network dominated by family members still increases one's contact with other ages and the other sex, while it makes the interpersonal environment more homogeneous with regard to race.

[...]Americans are still stratified on education and race. Higher education people have larger networks of both family and non-family members, and their networks have more of the range that tends to bring new information and perspective into the interpersonal environment. Non-whites still have smaller networks than whites.

[...]Our final estimates, corrected for response problems and demographic shifts, are that (1) the typical American discussion network has slightly less than one fewer confidant in it than it did in 1985 [about 3 in 1985, down to 2 in 2004], and (2) that in 2004 an adult, non-institutionalized American is much more likely [nearly 50%] to be completely isolated from people with whom he or she could discuss important matters than in 1985.

This is a major social change. Most people talk about personal matters only to a family member, a spouse is the common choice. Most no longer have a best friend outside of the family. Meanwhile, divorce is more common than it's ever been. I think close relationships are most likely to shape attitudes and values. Since we tend to share values with our family members, we have fewer inputs of diverse viewpoints and behaviors, especially from people we respect. People place greater importance and stress on the few close relationships they have to meet their social needs.

There is less diversity in our social support system especially of a cultural nature. Therefore we are exposed to a narrower range of ideas and our opinions are less likely to be as broadly based as they have been in the past. Americans are less likely to understand other cultures or tolerate a divergent lifestyle.

Support networks have become more like a closed system. Closed systems are known for their rigid rules of conduct, intolerance towards nonconformity, and oppression of divergent behaviors. They also are known to be inflexible to outside changes, less likely to adapt smoothly to environmental changes, responding instead with stereotypic oppressive responses to members attempting to find a better solution. The cost of nonconformity too often is a loss of access to the close social support needed to cope and adjust to a rapidly changing social environment.

Just when life in America is getting more complicated, Americans are losing some of their creative flexibility. Much has been said of the rising hours on the job, the prevalence of two income families, and the frequent job changes and inter-city migration. Income and buying power peaked in the 1990's during the surge of information industries. Enthusiastic growth gave way to oversupply and the so called "dot com" crash. The number of six figure incomes dropped precipitously. People are still working longer hours, but now it's to maintain or retrieve lost income or make up for higher costs of living.

The social retrenchment is understandable from this perspective. People are focused more in income security, less on social ties. Many people recognize they are just a few months of unemployment away from homelessness. It's as if American families are circling their wagons to cope with an increasing cost of living and stagnating incomes.

Why is it that Americans seem to lack an understanding of the importance of social support? Perhaps most evident in urban and suburban settings, people are now seeing a wider diversity of cultures and behavior patterns than ever, at a time when they have a lessor capacity to integrate this knowledge.

Sullen isolating attitudes are most evident on public transportation. Few people talk on buses, eye contact is avoided. Clearly people are afraid of meeting new acquaintances. News accounts of heinous violent crimes create an appearance of danger in meeting strangers. With people increasingly intolerant of divergent behavior, strangers who do find themselves in conflict expect a problem and lack the skills needed to find a win-win solution to the conflict. Too often, both parties go away feeling like the loser or at least frustrated with an impasse. While the danger of violence and crime is still relatively uncommon and presenting a low risk to the average city dweller, clearly, people believe they are at risk and they protect themselves by walling themselves off from new acquaintances, especially if they are different.

Basic social skills and emotion management never have been taught formally. Traditionally, emotion management and social skills were taught at home in resolving conflict with siblings under the tutelage of a stay-at-home mom. Now, however, most kids have their first social exposure in day care settings supervised much more loosely by a largely paraprofessional staff with little training beyond what they learned from their own childhood. At home, children are largely parented by the flickering screen while parents take care of routine chores until they join the children to rest in front of the TV. Its no wonder children have so much difficulty with conflict and grow up afraid of making new friends.

What is the solution? TheEditorInChief at Anxiety, Addiction and Depression Treatments has the traditional response to "Fixing America's Loneliness Problem".

As Dr. Putnam remarks in the Times' coverage, the number of friends we have is a strong indicator of how long we'll live. And while most strong friendships are cultivated in face-to-face interaction, our technologies offer us the ability to maintain ties when distance and reduced availability of time have forced a wedge between acquaintances.

Trends will not change on their own and maintaining friendships may not be easy work. But as with anything worth having, we must be willing to work for our friendships. Take a moment to think about those who you may still hold dear, despite what time and distance may have done to your connection. Each of those people is only an email, or heck, even a text message away. By taking up the tools that our new age has given us, we don't have to live lives of loneliness. We have the option to stay in touch, and as broadband expands and computer processors increase in strength, we will be able to see one another face to face again very soon on web cams and broadband phone calls. Hold onto your family. Ask those close to you about the things that really matter. Don't be afraid to reach out. You might be surprised at how ready those around you, or indeed, on the other side of the continent, are to answer you call.

Truly most of us can only hope to have an impact one person at a time, so the above suggestions are sound advice. But as a society we need to respond to what increasingly is looking like a deterioration of social conditions in America. People are increasingly isolated with no indication that this trend will reverse. A broad based shift in responsibility of teaching social and emotion skills must be recognized and dealt with planfully and competently. Ignoring this shift and claiming mothers should stay home with their children will not make it so. Incomes have stagnated and mom's salary is needed now more than ever just to maintain housing and food. Neglecting this new responsibility brings more chaos to the streets, increasing isolation, and the more inflexible stereotypic and counter productive responses will become. Families, functioning like closed systems are not very successful at adjusting to change, they too often fly apart and cease to function as a viable source of support for it's members. Too many end up on the margins of our society, vulnerable to crime victimization and criminal behavior.

Daniel Goleman in his book Emotional Intelligence, called for teaching emotion management in schools. Emotion management must be taught side by side with basic social skills, beginning at the child's first contact with other children. Parents have never received any formal training, day care providers and elementary school teachers have seemingly too little. Yet changes are beginning to come. Goleman reports on a number of curriculums written and pilots run with good research results. My wife, a paraprofessional staff in the local elementary school, teaches a regular class titled "Character Ed" where the values of integrity and conflict resolution are taught in creative ways using multi-media guaranteed to capture the attention of the youngsters. But more is needed. Schools and day care providers have yet to accept their responsibility to teach social and emotional skills. Taxpayers are not in the mood to fund a new expanded curriculum. But the alternatives are unacceptable.

Pay now, invest in future generations, or the chaos in the streets will come to your neighborhood soon. Let's avoid the tragic future of 21st Century Schizoid Man.

Hat tip to Crooked Timber for the link.

Go here!

Nikhil Rao in his blog OK so I’m not really a cowboy has an interesting article about the perils of taking diagnosis too seriously. He makes his point by noting that his tendancies to show schizoid and schizotypal traits is more a function of his chronic pain than a reflection of his personality.

He argues that diagnosis should not be about social acceptability or conformity but should reflect an more meaningful underlying process. In other words, diagnosis should be in part based on widely accepted constructs about internal psychological processes that reflect on etiology and cognitive and neurological function as well as behavior and symptoms.

The problem with schizoid and schizotypal PD I think is shared with anti-social PD. The concepts originated in psycho-dynamic theory representing internal states. The first two have been thought by some to be traits related to schizophrenia. Schizoid PD relates to a preferance for social isolation. Schizotypal PD relates to systematic errors in thought process like ideas of reference and magical thinking that appear to be a simple more common pattern similar to a thought disorder. Anti-social PD is most closely related to criminal attitudes and behavior.

When looking at a group of people in prison, most would have a number of traits suggesting anti-social traits. However, there are many reasons for a person to behave anti-social. Some grow up in families or subcultures that accept criminal behavior. Traditionally, the concept of anti-social comes from the psychopathy. Psychopaths are thought to have no or at least an unconventional conscience. Neurological studies suggest these people have underdeveloped or "immature" brains. The concept of anti-social PD adds so many people to the catagory that it deflects attention away from the causes of criminality towards the behavior itself. The value of concepts is largely rooted in their contribution to understanding. I see anti-social PD as muddying the waters.

The American Psychiatric Association adopted the Diagnostic and Statistical Manual (DSM) as it's diagnositic standard. It has steadily moved diagnosis towards a set of measurable criteria that is necessarily behavioral. Cognitions are not measurable in the traditional scientific sense. By taking us to “measurable”, the DSM de-emphasized the causes and internal processes that created the diagnostic construct. At the same time, the DSM effectively added a significant number of people who would not fit the constructs internal process and etiology. I would argue that many now fit a particular diagnosis that do not belong there.

The risk here is that we forget we are also working with internal states rather than just behavior and symptoms. Diagnosis should have some relationship to theory and methods of treatment. Based on DSM, we treat symptoms and change behavior which may not be addressing the underlying problem that caused the behavior. If diagnostics is taught solely within DSM nosology, we turn out diagnosticians who know little more about how to help someone, not qualified mental health professional who have an in depth understanding of psychology and the art of treatment.

Diagnoses don't reflect real phenomena, they represent conceptual models that are by and large still, in a way, experimental. Theoretically, diagnosis should lead us to treatment methods. While an experienced clinician sees some guidance in the diagnosis, it's still more about art than science. The DSM tries to make diagnosis more scientiific but in the end guts important content and understanding.