Clinician's Digest Sept/Oct 2012

What does a plastic toy crocodile have to do with autism? "The crocodile is the mother's belly, the mother's teeth," child psychoanalyst Genevieve Loison explains in an interview for director Sophie Robert's controversial new documentary The Wall: Psychoanalysis Put to the Test for Autism. "The goal of our work is to forbid her to eat."

The documentary spotlights current psychoanalytic views of autism in France, which echo the "refrigerator mother" theory dominating American thinking about autism and schizophrenia in the 1950s that damagingly blamed many mothers for the severe mental illness of their children. These views are raising concerns about how the developmental disorder is treated in that country.

Dozens of French psychoanalysts interviewed for the film espouse outdated and seemingly preposterous ideas about autism as a "psychotic" condition stemming from "maternal madness," parental frigidity, and gestational fantasies in utero. In response, many parents and advocacy groups are condemning France's psychoanalytic and institutional treatment methods for children with autism-still prevalent long after most other developed countries have shifted to behavioral and educational approaches-as dangerously reactionary and counterproductive.

Misguided mental health attitudes like those portrayed in The Wall can have dire consequences, especially for a disorder like autism, for which early diagnosis and treatment are essential for lasting success. Daniel Fasquelle, a French parliamentarian and mental health advocate, told the BBC that "if you diagnose early and then give the right treatment between the ages of 2 and 7, 70 percent of autistic children can acquire functional language skills. Here in France, we are way off that figure." Consequently, France has fallen drastically short in care for children with autism. According to French government reports, less than 20 percent of autistic French children attend school. In other developed countries, including the United States and Britain, nearly all autistic children go to school or receive special education. The problem is so bad that the European Committee of Social Rights issued a public condemnation of France's educational care for persons with autism in 2003.

French psychoanalysts in particular are receiving heavy flak, accused of creating and perpetuating a cultural mental health crisis. In a statement for the Association for Science in Autism Treatment, David Celiberti and Catherine Maurice remarked that the country's psychoanalytic community "has been unable to produce credible evidence for its assertions, has robbed children of their futures, and has abdicated responsibility for the harm they have caused families. . . . Children with autism deserve better."

Others feel that psychoanalysis is getting a bum rap. "The film [The Wall] is unfair," French psychoanalytic historian Elisabeth Roudinesco told the New York Times. "It is fanatically anti-psychoanalysis. But I don't think [Robert] manipulated the film to make them look ridiculous; rather, I think she chose to talk with very dogmatic psychoanalysts who come across as ridiculous." Asked what psychoanalysis has to offer autistic children, one analyst had this enigmatic answer for the filmmaker: "The pleasure of taking interest in a soap bubble. I can't answer anything else."

Three analysts successfully sued the filmmaker to have their interviews removed from the documentary. French psychoanalyst Eric Laurent said that "psychoanalysis is being used as a scapegoat" and that, although behavioral methods are effective, their circumscribed focus may fail to address other meaningful dimensions of autism.

WIERD Science

Imagine a world populated by college undergraduates. A world filled with binge drinkers and sleep-deprived procrastinators tweeting their sexual exploits to virtual friends across the globe. In most psychology studies, these are exactly the people from whom psychology researchers extrapolate fundamental truths about human nature.

Although North American college undergraduates make up only about 0.2 percent of the world's population, they account for a massively disproportionate number of psychology research subjects. In 2008, psychologist Jeffrey Arnett reported that in major social and personality journals, 67 to 80 percent of samples are comprised of college undergraduates. In fact, a college student in this country is 4,000 times as likely to be a psychology research subject than almost anyone else in the world.

University of British Columbia psychologists Joseph Henrich, Steven Heine, and Ara Norenzayan note that psychology studies are by and large conducted on a WEIRD (Western, Educated, Industrialized, Rich, and Democratic) bunch. These WEIRD studies create an odd problem: psychologists often tout their results as generalizable truths about human brains, beliefs, and behaviors. But if the samples aren't representative of the rest of the world, then just how representative are the results?

Henrich and his colleagues suggest, for example, that American study volunteers are more fiercely individualistic than others. They highlight one example of this difference reflected in work on moral reasoning. WEIRD studies lead us to believe that most people progress in their moral development to a stage of internalized standards based on a sense of personal justice, autonomy, and individual rights. However, studies outside of Western samples indicate the existence of a wider range of ideas about morality. The ethics of other societies often focus, much more than Western students do, on the obligations of social roles and community, as well as the centrality of divinity and religious values. Where Western undergraduates feel freer to smoke, drink, and show up for class in sweatpants, non-Westerners might, for example, view these behaviors as contrary to their religious edicts and internal beliefs about achieving spiritual growth through material abstinence.

American undergraduates might not even be representative of Americans as a whole. College students tend to be more self-focused, atheistic, culturally tolerant, and politically liberal than the rest of the country's population. Psychology students who make up study volunteer pools are predominately white, single, young, and female.

Given that college undergraduates are a readily accessible and captive data source, how are university-based psychology researchers supposed to push beyond the confines of WEIRD science? Enter the Internet. University of Texas personality researcher Samuel Gosling and colleagues propose that Internet-based studies have the potential to reach a much wider participant sample. Internet studies can now be designed for a range of research tasks, including survey collection, experimental designs, and even reaction-time monitoring. Some researchers are now turning to crowd-sourcing Web services that assimilate large communities of people who have signed up to take surveys and polls in return for modest payments. While such methods are still unlikely to reach smaller nonindustrialized societies, at least Internet research can expand the diversity of gender, education, age, ethnicity, and culture informing behavioral science.

Undergraduates may find it weird to think about life outside of college, but the rest of the world is starting to realize that universities are pretty WEIRD places to study.

Old Pills, New Promises for PTSD

With nearly eight million Americans affected by the symptoms of post-traumatic stress disorder (PTSD) and tens of thousands of troops returning from military operations in Iraq and Afghanistan, researchers are hard at work trying to identify new, effective treatments for the disorder. Currently, there are only two FDA-approved medications for the treatment of PTSD: sertraline (Zoloft) and paroxetine (Paxil). The evidence of the effectiveness of these antidepressants and other medications used "off-label" for PTSD-related symptoms is limited, and the medications often cause problematic side effects, such as sexual dysfunction, weight gain, and fatigue, which many users find disagreeable. New studies suggest that two drugs previously used for very different purposes may provide hope for PTSD sufferers. Unlike other psychiatric medications, these drugs aren't intended to treat the symptoms of PTSD directly--they're meant to augment traditional psychotherapy approaches for the disorder.

The first drug, ethylenedioxymethamphetamine (MDMA), is better known by its street name: Ecstasy. MDMA proponents suggest that the mood-mellowing effects of the drug may allow for more controlled and efficient processing of traumatic material in psychotherapy sessions. After years of campaigning, researchers from the Medical University of South Carolina and the Multidisciplinary Association for Psychedelic Studies in California received federal approval for the first randomized controlled clinical trial of this illegal recreational psychedelic party drug for patients with chronic PTSD. Under close clinical monitoring and in conjunction with intensive psychotherapeutic engagement (two eight-hour experimental sessions), 20 participants were randomized to administrations of either MDMA or placebo. In this admittedly small trial sample, 83 percent of the MDMA group exhibited substantial treatment response compared to 25 percent in the placebo group. The study results suggested that MDMA could be administered without severe adverse effects and may provide significant clinical results where other treatments have failed.

The second drug being investigated isn't found on the streets but behind the pharmacy counter. D-cycloserine is a broad-spectrum antibiotic commonly used for the treatment of tuberculosis infection. Researchers discovered that, in addition to its ability to fight off infections, the drug activates neural receptors in the brain associated with learning and memory formation. When treated with d-cycloserine, both rats and humans can learn fear extinction more quickly, requiring far fewer trials to extinguish fear of a nonharmful stimulus (e.g., a flashing light) that had previously been conditioned with an aversive stimulus (by pairing the light with a painfully loud noise, for example). This accelerated learning curve, researchers suggest, may hasten the effects of behavioral psychotherapies targeting the extinction of PTSD symptoms.

A recent clinical trial found that giving d-cycloserine to patients participating in exposure therapy for severe and persistent PTSD led to improved outcomes for the behavioral treatment. Rianne de Kleine, a researcher form the Centre for Anxiety Disorders in the Netherlands, the study's first author, said "Our study showed that some PTSD patients respond well and fast to exposure [psychotherapy] and, for them, there seems no need to augment the therapy. In contrast, those patients with severe PTSD symptoms who fail to respond to exposure sessions may benefit from augmentation with d-cycloserine."

While experimental findings for these old drugs in new bottles are exciting, the research is still in its infancy. MDMA may go the way of its psychedelic-assisted therapy predecessor LSD, and d-cycloserine may fail to live up to its promises, just as other psychiatric wonder drugs have. Yet, if these drugs prove successful, therapists might one day ask their anxious patients to "turn on, tune in, and drop out," while a drug once geared to a disease of the lungs may help soothe the traumatized mind.

"Manpocalypse Now"

Psychologist Philip Zimbardo knows a thing or two about tough guys. In 1971, his notorious Stanford prison experiment, originally planned for two weeks, had to be shut down after only six days when college students acting out roles as prison guards started to play a little too rough with their mock inmates. In 2007, he tried to understand the military abuses at Abu Ghraib prison in his book The Lucifer Effect: Understanding How Good People Turn Evil. Now he turns his attention to a different kind of prisoner: the average American male shackled by the constraints and demands of societal expectations.

In a new eBook titled The Demise of Guys: Why Boys Are Struggling and What We Can Do about It, Zimbardo and his coauthor psychologist Nikita Duncan paint a dire picture of dudes in this country, asserting that boys are increasingly failing to measure up academically, socially, and sexually. The blame, they say, lies with the Internet, television, and video games. According to their view, a new Lost Generation has grown up, addicted to arousal and constantly seeking stimulation and novelty through digital means: "The excessive use of video games and online porn in pursuit of the next thing is creating a generation of risk-averse guys who are unable (and unwilling) to navigate the complexities and risks inherent to real-life relationships, school and employment." More young men are supposedly languishing in their parents' basements, aimless, asocial, and out of touch.

The signs of the decline, they say, are everywhere: falling test scores, violent video gaming, and a buxom pornography industry. Zimbardo describes a "social intensity syndrome" in which men are driven to engage in intense, male-dominated social interactions leading to an endorphin rush that the rest of their dull daily lives just can't match. During a popular TED talk, Zimbardo said "Guys would rather be in a bar with strangers, watching a totally overdressed Aaron Rodgers of the Green Bay Packers, than Jennifer Lopez totally naked in the bedroom."

Boys aren't the only ones struggling, suggests psychiatrist Boadie Dunlop, director of the Mood and Anxiety Disorders Program at Emory University. With the economic downturn's hitting men particularly hard, they're relying more heavily on women as the primary household earners. While traditionally female-populated fields like healthcare and social services are experiencing burgeoning demand, "manly" occupations like construction and manufacturing are being scaled back and reorganized for greater efficiency. Many men are finding themselves outsourced, obsolete, and out of work. "Compared to women, men attach greater importance to their roles as providers and protectors of their families," Dunlop says, "and men's failure to fulfill the role of breadwinner may lead to greater depression and marital conflict."

Zimbardo and Duncan may be sounding an alarm about masculinity in crisis, but concerns about the death of manhood have been around for decades, if not centuries. Pornography isn't new, even if it's now more accessible on the Internet. Many video gamers would protest that gaming is more interpersonally interactive today than ever, and our wired world is used much more for social networking than social detachment. Are entertainment addictions really a more pervasive societal concern for men than rising housing costs and ballooning student loan bills? Is the fact that men are living with their parents longer and postponing marriage and childrearing a sign of "Arma-guy-ddon" or just a smart social adaptation to an economic "man-cession"? Only time will tell.

Jared DeFife

Jared DeFife, PhD, is an Atlanta psychologist specializing in caring counseling to help passionate professionals overcome self-doubt, shame, and insecurity.


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