Stanley Milgram’s classic experiments in the 1960s demonstrated that ordinary people would—with encouragement from authority figures—give escalating electric shocks to innocent people so painful that the subjects, who were actually in league with the researchers, would scream in pain. Some critics have dealt with Milgram’s troubling findings by pointing out that his studies have never been replicated, making it easier to treat his outcomes as a possible anomaly or even slipshod research. But they continue to haunt us.
When the scandal at Abu Ghraib broke, with its photographs of American soldiers torturing and humiliating prisoners, Muriel Pearson at ABC News Primetime remembered Milgram’s studies and asked Jerry Burger, a professor of psychology at Santa Clara University who’s researched social obedience, to replicate the famous experiment. Burger explained that because of ethical research guidelines put into effect since Milgram’s work, it wasn’t possible. But he continued to ponder the ABC request, not just for the challenge, but to prove a point.
“People keep saying that what Milgram found could never happen again,” Burger says. “But it can be dangerous to think that people change and get better if they haven’t.” Finally, Burger found a way to partially replicate the study and received the go-ahead from an independent review board.
To deal with the ethical considerations, he made some modifications to the setup of the original study. He stopped subjects at the 150-volt mark, the point at which Milgram’s sham confederates first began to protest about the pain and demand to be released. (Milgram talked his subjects into “administering” 450 volts). This helped avoid the main ethical problem with the first experiment: several of Milgram’s subjects were traumatized by the sham participants’ pleading and screams, and by their enduring shame and guilt about what they’d done.
Further safeguards included prescreening participants for psychological vulnerabilities to stress and trauma. This excluded about 30 percent of Burger’s potential subjects. Those remaining were screened again with written instruments and interviews by clinicians instructed to be overcautious in deciding whom to approve. Nearly 40 percent of the remaining group was also excluded. Subjects who passed both screenings were told at least three more times that they could withdraw from the study at any point. Immediately after the experiment, they were carefully debriefed.
The outcome: Burger documented obedience rates only slightly lower than those of the original experiment. Milgram found that the 150-volt mark was the point of no return for 79 percent of the participants—once they passed that mark, they continued up to 450 volts. Therefore, Burger believes that most of his participants would have “administered” stronger shocks if the study had continued.
Now that Burger has put the ethical dilemma of replicating Milgram’s experiment to rest, he hopes others will pick up on the long dormant and disturbing research. It appears that Stanley Milgram was right: whether it’s Abu Ghraib, a Yale University lab, or some situation in next week’s headlines, when authority figures give direction and permission to do abhorrent things, people are likely to comply.
Depression and Biology
The antidepressant marketing blitz that’s sold millions of people on an overly simplistic connection between depression and low serotonin levels has obscured the fact that many psychiatrists have a much more complex view of depression’s biological causes and cures. A dramatic first-person article by Marlene Belfort in the October 30 New York Times helps alert therapists and the public that a malfunctioning thyroid, which regulates several hormones and neurotransmitters, can sometimes make therapy and antidepressants as useless as an umbrella in a hurricane.
Belfort, a research scientist in developmental genetics and bioinformatics with the Wadsworth Center of the New York State Health Department, writes that she had four years of psychotherapy for her mild depression, dealing with her father’s suicide and other issues. Three years after therapy successfully ended, she lapsed into a worse depression. She saw a psychiatrist, but despite different combinations and doses of antidepressants, her depression deepened into psychosis. She later had shock therapy, was better for a while, and then suffered three more relapses. Finally, her psychiatrist ordered a blood work-up, and discovered she suffered from hyperparathyroidism, a condition that affects about 100,000 Americans annually. Hyperparathyroidism is only one of several thyroid or adrenal disorders linked to depression. After two surgeries to control her hyperparathyroidism, Belfort has gone three years without another significant depressive episode and is cautiously optimistic.
How can therapists who treat moderate to severely depressed clients know when to think beyond psychosocial events and serotonin? In his 2000 book, The Antidepressant Survival Guide, psychiatrist Robert Hedaya, professor of psychiatry at Georgetown University, presents separate checklists to help determine whether a depression might be caused by malfunctioning thyroid or adrenal glands. Among the dozens of possible indicators: weak muscles (especially in the upper arms and thighs), unexplained weight fluctuation, dry skin, hair loss, swelling in the hands or feet, puffiness below the eyes, irregular menstrual periods, a craving for salty foods, excessive tiredness, dizziness or light-headedness when standing, an increased tendency to bruise, or darkening of the skin around elbows, knuckles, palms, knees, or nipples.
Not all therapists pay sufficient attention to possible biological causes of depression. Belfort’s article serves as a reminder that therapists should make sure that they refer to psychiatrists who consider thyroid and adrenal problems before handing out an antidepressant prescription. The simple blood tests may head off months of anguish and deterioration.
Mars and Venus Realign
By now it’s become a matter of conventional wisdom that men are from Mars and women are from Venus, but are they really? University of Wisconsin psychologist Janet Shibley Hyde’s review of 46 metanalyses on gender differences, published in the September 2005 American Psychologist, concluded that for 78 percent of the variables commonly supposed to differentiate one gender from the other, there was negligible or no difference.
After examining studies of gender differences in such areas as cognitive abilities, communication, social behavior, personality, and psychological well-being, she concluded that for such commonly supposed gender-specific attributes as indirect aggression, leadership style, self-disclosure, moral reasoning, and delay of gratification, within-gender variability was much greater than between-gender variability. Men do throw harder, masturbate more, exhibit slightly more direct aggression, and endorse casual sex more strongly, but that’s about it.
Expectations often color objectivity, and the fact that some therapists buy into the common myths about gender differences may help explain why men often feel at a disadvantage in couples therapy, where women are supposedly so much better able to talk about feelings. Expecting less input from their male clients, therapists may miss the input when it happens, or reinforce spouses’ views that their men are biologically indifferent or incapable of being emotional. (Therapists who want to examine their own implicit assumptions about gender can take an online association test that measures unconscious gender bias, at http://www.understanding prejudice.org/iat/.)
Hyde advises therapists to think in terms of gender similarities instead of differences. She believes that therapists who follow the Mars/Venus paradigm may inadvertently steer couples away from finding their emotional connections toward better communication.
A Single Treatment for PTSD?
When the Department of Defense asked the prestigious Institute of Medicine (IOM), an arm of the National Academy of Sciences, to determine the most effective treatments for post-traumatic stress disorder, the hope was that this would put treatment decisions for thousands of veterans suffering from PTSD on a solid empirical foundation. But after reviewing 90 clinical trials of different medications and therapies, the IOM report concluded that only exposure therapy was effective, a finding which has created more controversy than consensus.
According to the report, studies on every other medication and therapy frequently used to treat PTSD—including EMDR, cognitive restructuring, coping skills training, and psychodynamic and group therapy—were too compromised by methodological limitations or didn’t have enough positive results to demonstrate their efficacy.
Proponents of treatments that didn’t make the grade have strongly challenged IOM’s conclusions. Some researchers, including John Carlson, former editor of the International Journal of Stress Management and author of an EMDR study which the IOM report found lacking, wrote the IOM committee that they’d ignored or misstated information in several studies. Critics also complained that a number of treatments IOM failed to find effective are recommended by prestigious mental health and governmental organizations around the world. For example, Britain’s Cochrane Report of April 20, 2005, prepared by a group of international health care reviewers, endorses stress management and EMDR as PTSD treatments, with EMDR’s efficacy matching that of exposure therapy.
Even supporters of the IOM report, like PTSD expert Richard McNally, director of clinical training at Harvard University, agree that the IOM used unusually rigorous standards, raising methodological issues often overlooked by reviewers. For example, the IOM was dissatisfied with the way many studies handled treatment dropouts. It criticized studies run by people with a “financial or intellectual interest” in the outcome, although other organizations believe that the risk of researcher bias is outweighed by the fact that familiarity with a treatment helps ensure it’s conducted correctly. Some approaches that have proven to be effective with PTSD were discounted because of the restricted populations they examined. The IOM felt, for example, that what works for a rape victim with PTSD may not work for a soldier. While McNally sees in this a move by the IOM to improve research guidelines, critics like Carlson accuse the report of selectively moving the goalposts to favor exposure therapy.
Although the IOM stresses that its report isn’t saying that other treatments are ineffective—it’s merely calling for more research on them—the Department of Veterans Affairs (VA) has announced that it’s ramping up efforts to train its staff in exposure therapy. Larry Scott, founder of VA Watchdog, a veterans’ advocacy group, contends that the IOM report furthers the VA’s real intention: to curtail spiraling disability benefits by narrowing the diagnosis and treatment of PTSD.
Critics have long claimed that efficiency in the health care system is too often achieved by narrowing the definition of a disorder and limiting treatment objectives, leaving many prospective clients without access to any care and forcing others to settle for abbreviated treatments. Scott fears that the long-term effect of the IOM report will be that veterans are called upon to make yet one more sacrifice—this time, in the name of treatment “efficiency.”
Meditating for Clients
In the January/February Psychotherapy Networker, Jerome Front wrote about training therapists to do mindful meditation—not to learn an anxiety-or stress-reducing technique that they can pass on to their clients, but to enhance their own therapeutic insight and skills. A study reported in last October’s Psychotherapy and Psychosomatics supports Front’s view of the clinical value of meditation for therapists.
Specifically, the study looked at whether psychotherapists in training who worked on an inpatient psychiatric unit would do better therapy if they meditated. The researchers randomly assigned nine of the therapists, who’d had no experience with meditation, to meditate with a Zen master for an hour before their workday during their entire residency. Following each meditation session, the therapists progressed through their rigorous work week of individual and group therapy sessions, social skills trainings, psychoanalysis, and so on.
After nine weeks of treatment, their patients were evaluated and compared to the patients of nine therapists who hadn’t meditated. The results: the patients of the meditating therapists scored significantly higher than the control group on almost every measure of global functioning, subjective experience, objective behavior, and symptoms. They were more secure about socializing and exhibited less obsessiveness, anger, anxiety, and phobias. They better understood the goals of their own development and of their therapy, and were more optimistic about making progress. They’d developed a wider repertoire of new behaviors as well.
The study suggests that therapists could do better therapy by focusing at least as much on their breathing and calm awareness as on learning clinical techniques.
The Therapist–Client Alliance Gap
Research clearly shows that therapists and clients typically rate the quality of their alliance differently, with clients generally rating the alliance a bit more positively. But sometimes clients rate the alliance lower than therapists do, and it seems that these are the cases most likely not to work out, or to end in premature terminations.
Psychologist Georgiana Shick Tryon, of the Graduate Center of Educational Psychology of City University of New York, whose metanalysis of 53 alliance studies appeared in last November’s Psychotherapy Research, believes that therapists should regularly ask clients how they’re experiencing the relationship and pay particular attention to those few who rate the alliance lower. That’s similar to the advice from other therapy-outcome researchers, such as Michael Lambert of Brigham Young University, who’ve found that therapists who receive regular feedback from clients about how therapy is going, especially early in the relationship, have much better outcomes.
Several instruments are available to help therapists regularly assess how their clients experience the alliance. Tryon recommends the Helping Alliance Questionnaire (HAQ) which seems to yield more convergent therapist–client ratings than the Working Alliance Inventory (WAI). This may be, she says, because the WAI has questions that invite each person to speculate about what the other is thinking and feeling, and such mind-reading builds in discrepancies. A short version of the WAI, the WAI-SR, eliminates the mind-reading questions. To improve their outcomes, therefore, she thinks therapists should consider using the HAQ or WAI-SR instruments. Therapists can download a free copy of the HAQ at www.med.upenn.edu/cpr/instruments.html
My Psychosis, My Self
Psychiatrist Michael Garrett, professor of clinical psychiatry at the State University of New York Downstate Medical Center, believes it’s important for his psychiatric residents to understand that psychotic thinking falls along a cognitive and emotional continuum they share with their seriously disturbed patients. “If you want to have a real conversation with a psychotic person,” Garrett says, “you have to believe and feel in your bones that you’re genuinely respecting the person’s experiences, and not just diagnostically labeling and pigeonholing them.”
In a series of exercises, Garrett puts psychiatric residents in touch with their own thoughts and perceptions that offer analogies to psychotic states, and then explores and deepens them. Imagine, he tells the residents, you’re on your way out the door and suddenly realize you’ve got to make a quick phone call. After the call, you get into your car, drive a few blocks, get caught by a red light, and while you’re stopped, a friend whom you haven’t seen for 10 years crosses the street right in front of your car. You realize that if you hadn’t made that phone call, and if it hadn’t lasted exactly as long as it did, the two of you would have missed each other.
Garrett asks the residents if they’ve ever had a similar experience, and several invariably have. They recall having briefly thought at the time about things like fate, feeling the subtle pull on the mind of some process—benign or, in the case of paranoia, malevolent—operating beneath the surface of things. Then they recall talking themselves out of their irrational thoughts by accepting the randomness of coincidence or mulling about the statistical probability of the encounter. “Now, what if such things happened to you weekly or even daily?” Garrett asks. “What if you couldn’t talk yourself out of your irrational thoughts?”
In another exercise, Garret helps residents experience how paranoid people invest everyday images with self-referential meaning. Have they ever passed a police car parked on the highway shoulder, which then pulls out and starts driving behind them, he asks. “You’re temporarily encapsulated in a microcosm in which you and the policeman are engaged in an intense drama,” resulting in heightened anxiety and the expectation of possible punishment, Garrett says to the group. “Fear, guilt, shame, and other intense emotions shape what the psychotic person sees and hears in the world around him all the time.”
Milgram: APS Observer 20, no. 11 (December 2007). A complete presentation of Burger’s study is in press with American Psychologist.
Mars/Venus: Current Directions in Psychological Science 16, no. 5 (October 2007): 259-63; American Psychologist 60, no.6 (September 2005): 581-92.
PTSD: IOM report at http://www.nap.edu/catalog.php?record_id=11955.
Meditation: Psychotherapy and Psychosomatics 76, no. 6 (October 2007): 332-38.
Alliance Gap: Psychotherapy Research 17, no. 6 (November 2007): 629-42.
Psychosis: Psychology and Psychotherapy: Theory, Research and Practice 79, no. 4 (December 2006): 595-610.