Docsplainin' -- it's what I do

Docsplainin'--it's what I do.
After all, I'm a doc, aren't I?



Saturday, January 24, 2009

Blind Obedience

or, Some Things Never Change

Umpty-ump years ago, Stanley Milgram, a Jewish psychologist interested in better understanding the Holocaust, began a series of experiments to see just how far ordinary citizens would go in obeying orders to harm another person. In the best-known of these demonstrations, 65% of his study subjects shocked (as far as they knew) another human being clear into unconsciousness and (for all they knew) possibly even death. This, even in a situation in which it was perfectly safe to tell the authority figure where to stuff it. As one of my students put it the other day, "People are sheep."

However, as Miller (2009) notes, over the entire series of experiments (there were 16 in all), 60% of Milgram's 540 subjects disobeyed orders at some point. So not all people are sheep, and some are sheep only up to a point.

Reasons (some) people are sheep (up to a point) include that, in our culture at least, we are socialized to obey authority. Children who mind well are valued, whereas those who don't are punished or taken to therapy or both. We even have a diagnostic code for particularly willful little brats: We label it a mental illness, Oppositional Defiant Disorder. I would also submit that the child who obeys is the child who survives to maturity and reproduces. Children who play with fire, run with scissors, and dart out into traffic do not. It's that simple.

We don't, of course, raise our children to be cruel. This underscores Milgram's point, which was that it is really the situation which is the most powerful factor in producing destructive obedience, not our national character or our individual personalities (Blass, 2009). This also explains why people, you and me included, will predict based on self-knowledge that they would never do something like this, and then most will, if conditions are right. You and I might, too. The trouble is that we don't know as much as we might about what situational variables have what effects. In any event, we can't control situations. We can, at least potentially, control our reactions. But to do that, we need to know more. We need to know what characterological traits enable us to prevail over even the most powerful situations. But let's get back to the list of reasons why we act like sheep sometimes.

Sheep-ish behavior can be induced by degrees. In the Milgram studies, as is often the case in real life, people eased into bad behavior--in this case, 15 volts at a time. What's 45v when you've just administered 30? ...165 when you've just administered 150? Hitler didn't start out saying, "You're gonna personally slaughter 6 million Jews and several millions more gays, gypsies and people with disabilities." No. He started out just talking bad about them, which got people ready to make them wear the Star of David or a pink triangle or whatever on their sleeves, then he took away some relatively minor civil rights, working his way up to Kristallnacht and such. He crept up on rounding them up and killing them, one small step at a time. And the sheep--whoops! I mean, people--went along with him. Not everybody, of course, but enough so that he could get the job done.

Sales people are trained in a similar technique: Get the consumer to say "yes" to as many questions as you can ("wouldn't you prefer a car that is reliable? beautiful? American-made?" Well, of course) before you spring the ultimate question ("Will you buy this car?") on him and he will say "yes." It's a tried-and-true technique. Milgram got people to say "yes" to 15v and worked them up 15v at a time until they were administering potentially lethal shocks using this method. Hitler got people to say "yes" to talking ugly about Jewish moneylenders and worked his way up to "yes" to the cold-blooded slaughter of unarmed women, innocent children, and helpless cripples. It was easy. And it only took a few years to talk a couple of million people into this madness.

Which brings us to #3. We tend to do what the rest of the flock group is doing. It's called group think and many, many studies have documented just how distorted (and extreme) our thinking can get when the group not only doesn't offer a corrective point of view but is actually leading us to the fringe. Fourth, when somebody is telling you to do something, you can slough off responsibility. "I was only following orders" echoes down through history as justification for all kinds of moral failings, ethical violations, and crimes against humanity, from Andersonville to Abu Ghraib. "Baaaa," quoth my student. The sheep will follow the goat.

Most interesting, however, is the sloughing off of responsibility onto the victim. Milgram found that subjects who obeyed ascribed twice as much of the responsibility for what happened to the victim, compared to subjects who resisted (Blass, 2009). Milgram thus may have been the first scientist to document the blame-the-victim phenomenon which Hitler so ably exploited in turning his countrymen against the Jews.

In Jerry M. Burger's (2009) replication of the Milgram studies, which just landed in my mail box last week, one variation in the experimental condition was to have a confederate model noncompliance. This had nearly zero effect on rates of obedience among experimental subjects. However, when two confederates modeled noncompliance in the original Milgram studies, experimental subjects also refused requests to shock their victims any further. It seems that if there is a group of people doing the right thing, it becomes easier for us to resist malignant authority--it gives another, perhaps more palatable, group to join. We don't have to give up the safety of the group in order to follow our conscience: The new group presumably offers us more or less the same benefits as the old one.

Unfortunately, in the real world, there may be no effective individual models for resistance, never mind groups. Evil organizations tend to screen those folks out where they don't self-eliminate, so that for the individual at a moral or ethical decision-point the only available behavioral models may all be torturers and murderers who furthermore are skilled at socializing the novice into the group pathology. An example would be a corporation headed by a sociopath. He (and the stats are that it usually is a "he," guys, so don't get your dander up) will intuitively, if not consciously and deliberately, hire like-minded folk. Who will in turn hire more of the same to work in various corporate departments and branch offices. The occasional non-psychopath who accidentally gets hired will either leave on her/his own, get co-opted (i.e., turned into a sociopath), or be run out of the company. Or sit silently by while evil is done (Miller, 2009). So what you will wind up with over any extended period of time is a company full of sociopaths. But I digress.

Evolutionary psychologists would say that we are hard-wired to feel, think, and behave as a tribe, and it has obvious short- and long-term survival value for us to do so. Think about it: There's not much with a lower potential for long-term survival and reproduction than a single hominid alone on the vast African savannas, is there? Indeed, a half a million or so years later, among certain Plains Indians the most severe punishment available was to run an individual out of the tribe--an almost certain death sentence. And of course even today in dangerous professions such as police work or military service, "going along to get along" has immediate survival value. You have to be able to count on your comrades having your back (see Benjamin and Simpson, 2009, for further discussion).

Stage hypnotists know that the very fact of a subject's volunteering, the parameters of which act are defined by the way the invitation is framed and delivered, guarantees better (e.g., more easily hypnotizable or compliant) sheep--dang! I did it again--subjects for the show than if one picks them out of the audience oneself. Similarly, rates of obedience in an experiment or an SS unit may be higher than they would be in the population at large. Miller (2009) also makes this point.

Given all this, the wonder is that 35-60% of Milgram's subjects stopped when they did. Indeed, as Lee Ross (1998; cited in Benjamin & Simpson, 2009) wrote, "The Milgram experiments ultimately may have less to say about 'destructive obedience' than about ineffectual and indecisive disobedience" (p. 16).

Of course in Milgram's studies, nobody was really getting shocked, therefore, presumably, no one was harmed. Still, there were ethical concerns: It was pretty stressful for the study's participants, and we just don't do that any more. Consequently, in order to "replicate" the study, one would have to change the procedures pretty drastically.

Burger (2009) has done just that. His study stopped after participants thought they had delivered 150 volts to the confederates, whereas Milgram's study went to 450v. Burger selected this stop point because in Milgram's lab, most people who quit stopped there, while most people who crossed that line continued to the bitter end. Burger also screened out people (the depressed, the anxious, the traumatized) who might be harmed in the study. Alan Elms, who assisted in the original study, calls this "obedience lite" (2009, p. 33), more about which, later.

The question was, has anything changed? Are we more aware of the danger of blind obedience than we were 50 years ago? Would it make any difference if we studied women, too? Burger found that (1) no, it hasn't, (2) no, we apparently aren't, and (3) no, it doesn't. The latter probably will not surprise students of the Holocaust, who know that some of the most notorious concentration camp overseers were women SS. And some of you may recall that the poster child for Abu Ghraib was a girl.

Jean Twenge writes that, according to her research, young people today should definitely be far more likely to defy authority than a bunch of middle-aged white guys would have been in Milgram's day. She interprets Burger's data as showing a trend, albeit nonsignificant, in the direction of increased resistance to authority, and she points out several aspects of Burger's study which may have inadvertently suppressed further evidence of change (Twenge, 2009). Unfortunately for her argument, Blass, (1999, 2004; cited in Blass, 2009) did a meta-analysis of 25 years' worth of studies and found a "near zero" (p. 43) correlation between the time the study was conducted and the obedience rate.

Also, Twenge's analysis relies heavily on the sampling differences, and for Burger to use a sample more like Milgram's would have, in my opinion, rendered it ecologically invalid. We want to know what college-educated, ethnically diverse, gender-inclusive police and army units would do in the face of an illegal order. We want to know what a melting-pot populace like ours, asked to go along with a Guantanamo or a Patriot Act, would do. With the possible exception of corporate boards, exclusively white male groups like Milgram's study sample are, after all, scarce on the ground any more.

Twenge (2009) also argues that Burger's study confounds obedience with violence and lack of empathy. She notes that the increase in narcissism over the intervening generations since Milgram's day and the desensitization to violence from tv and video games may account for part of the "obedience" rate Burger found. The empathy argument won't wash, however, as Burger tested for empathy (and consequently, indirectly, for narcissism) in his subjects and found this trait not predictive of compliance/noncompliance. As for the violence argument, this is splitting some exceedingly fine semantic hairs. Who cares what we call it? The end result is the same. People will still hurt other people when told to and/or given the opportunity to do so. Baaaa. I am sure that from Andersonville to Auschwitz to Abu Ghraib, plenty of narcissists and violent people took full advantage of the opportunity to act out, side by side with sheep-ish folk who were merely "following orders."

A stronger argument is probably that of Elms (2009), who pointed out that by stopping the study at 150v, Burger effectively eliminated the most critical aspect of the original. And as a result, Elms argues, we cannot say whether people would still hurt, injure, and possibly even kill each other under orders. Maybe if the victims were still writhing, screaming, and finally falling silent, the increased independence that Twenge has documented in her work would have asserted itself and Burger's rates of disobedience would have been much higher. Or not: Burger's subjects were still arguably well within their comfort limits, but on the other hand, discomfort didn't seem to slow down many of Milgram's. We may never know, because the likelihood of getting such a study past an IRB these days is just slightly less than nil.

Elms and Twenge both express concerns that screening out people who would be "upset" by the study reduced disobedience. But that dog won't hunt, either. I would argue (again) that first, being upset did not appreciably contribute to disobedience in Milgram's original studies: In fact, one of the most notable findings was the degree to which people could be upset and still continue on with the experiment. Second, police and military organizations take great care to screen out the anxious, the depressed, the previously traumatized. If we want ecological validity in a study predicting what a soldier might do in, say, a My Lai-type situation, then we need to screen out the folk who wouldn't likely make it into an overseas combat unit in the first place. Works for me.

So while the "lite" factor is a big problem, I don't buy the other criticisms. From my point of view, the biggest disappointment is that we didn't learn something more about, to paraphrase Ross, effective, decisive resistance. Elms (1972; Elms & Milgram, 1966; as cited in Elms, 1990) conducted extensive psychological testing on subjects from Milgram's series who had obeyed or not obeyed, in an attempt to discover some differences. He found only nonsignificant correlations between obedience and authoritarianism.

As noted earlier, Burger had thought that maybe the degree of empathy a person generally has for others might make a difference, or the degree to which control was important to them, but neither personality trait proved to be a predictor. Neither were such demographic factors as gender, age, or level of education. The different ethnic groups weren't big enough, statistically speaking, to test.

So we still don't know why approximately 1/3 to 2/3 of people will refuse to obey an illegal order. To me, that would be the most useful information of all, and I hope somebody, somewhere, is working on that. Burger's was an elegant piece of work, and one can only hope that there will be lots of replications with variations intended to tease out what it is that allows some people to "just say 'no'" to human cruelty.


References

Benjamin, L. T., Jr., & Simpson, J. A. (2009). The power of the situation: The impact of Milgram's obedience studies on personality and social psychology. American Psychologist, 64, 12-19.

Blass, T. (2009). From New Haven to Santa Clara: A historical perspective on the Milgram obedience experiments. American Psychologist, 64, 37-45.

Burger, J. M. (2009). Replicating Milgram: Would people still obey today? American Psychologist, 64, 1-11.

Elms, A. C. (2009). Obedience lite. American Psychologist, 64, 32-36.

Miller, A. G. (2009). Reflections on "Replicating Milgram" (Burger, 2009). American Psychologist, 64, 20-27.

Twenge, J. M. (2009). Change over time in obedience: The jury's still out, but it might be decreasing. American Psychologist, 64, 28-31.

Saturday, January 17, 2009

A monstrous ethical dilemma

I just finished reading Stephen White's first novel, Privileged Information (Viking, 1991; 363 pp.). I'm surprised I'd never heard of him before, because I love murder mysteries and I particularly love those written by or about psychologists. But somehow I'd missed this one: A friend, in town for the holidays, turned me on to it. "Be sure and start with the first one," she said, and I did.



At first, I didn't like it. It wasn't all that well-written, in the beginning at least, and I thought the ethical problem was kind of contrived. But it picks up along the way.

Here's the dilemma. The novel opens with the suicide of a patient. The patient unfortunately wrote up her sexual fantasies about her therapist, the protagonist of the novel, in her diaries without identifying them as fantasy. The executor of her estate reads them, and thinking that the protagonist, Dr. Alan Gregory, not only may have been sleeping with his patient but may have precipitated her suicide by doing so, files a complaint.

Gregory certainly is in a bit of a pinch here, because the complaint hits the papers and of course the therapy community is abuzz about it as well. Gregory can say nothing in his defense, publicly at least, due to patient confidentiality. He of course can defend himself before the licensing board, but that is not the problem here. What felt contrived to me was that he seems to think he can't talk to his colleague and business partner, his lawyer, or even his clinical supervisor about the case, which is completely incorrect. He can. And should.

But this is a relatively minor flaw in the book, because as it turns out the privileged information of the title primarily refers to another patient altogether, one whom Gregory begins to suspect of murder. Now he really is in a bind, because he cannot reveal what the patient is up to without a more clear and convincing threat to a specific person. Which the patient is smart enough not to give him. So the rest of the novel turns around how to stop a killing without giving away privileged information.

Along the way, Gregory, who is completely innocent of the boundary violations with which he is charged, does manage to rationalize some other, serious ethical breaches. And his final solution is not ethically perfect, either. It's creative, though, and it does solve the problem.

White is himself a psychologist who practices in Boulder, CO. In his writing he gives a good picture of the life of a psychologist. But ethical issues not addressed in this novel include (1) Gregory seeing 38 people a week when his caseload is its usual size, and (2) Gregory continuing to work while his personal and professional life crumble around him. He also takes on a patient who represents a clear conflict of interest. He should have referred this guy on during the first session--but then, if he had, there would have been no novel, so I guess we're stuck with that.

Gregory makes boodles of money seeing 38 people a week, but my God. When does he do anything else? Like billing, charting, reading, eating lunch, going to the bathroom... He books people back to back, referring once to "my 3:00 and my 3:45" so he's not doing any of this between sessions. I once interviewed for a job with a psychologist who claimed to see 50 to 55 patients a week: My first instinct was to run like hell. That can't be healthy. You can't possibly, in my humble opinion, maintain a high standard of performance at that level.

He is also working with a couple while his own marriage is breaking up, and one has to wonder if how he sees his own relationship troubles is biasing his view of what the couple he's treating "should" do with theirs.

And finally, he takes on a client who had an affair with a former client. I wouldn't touch that with a ten-foot pole. Or as a former colleague of mine used to say, a 12-foot Russian.

So we hope White doesn't practice like that. And while the book gives a better portrayal of the profession than, say, Prince of Tides, I'd still warn you to take it with a grain of salt (it is, after all, fiction). The Alex Delaware novels by Jonathan Kellerman are much better in that regard. I've read them all and the worst thing I can recall Dr. Delaware doing is having a drink at lunch when he has a patient to see in the afternoon.

Tuesday, January 13, 2009

Rx

It has happened occasionally in my career that I have wound up holding drugs for a client. Sometimes, a client leaves them locked up in a file cabinet for safekeeping. More often, I have persuaded clients to turn over a "suicide stash," which my pharmacist disposes of for me. But never before have I confiscated meds prescribed to a person who the MD knew abused the drug, overdosed on it twice, and had even been in detox for it. Couldn't believe it.

Thursday, January 8, 2009

My apologies to every student upon whom I have ever inflicted these PowerPoint-isms. I promise to do better in the coming weeks.

Sunday, January 4, 2009

It's Called "Assertiveness"

Reassigned Time: Taking Care of Self = Losing Patience with Others

Crazy's got another great topic going over at Reassigned Time. She's figuring out on the 4th day of this New Year that to keep some of her Resolutions, she's going to not only be saying "yes" to things that are good for her, but saying "no" to other people's requests in order to clear the decks.

She wrote:
Well, I'm going to have to learn to say no more frequently and more forcefully, because if I keep saying yes to idiots, I will end by making a lot of enemies, I fear. So, perhaps the taking care of the body business and putting oneself before other things does actually produce the very results that the goal aims to produce, for it turns out that although I did not resolve to say no more frequently, I'll have to do so if I don't want people to hate me for being a meanie. This is kind of awesome.

She's learning quickly what I find to be true for women as a rule--to wit, that we tend to say "yes" to everything, and then there's either no time for the things that are really important to us, or we, in trying to do too much, wind up doing none of it very well. We miss deadlines, let people down, resent the hell out of them... and nobody's happy, least of all us.

I disagree, though, that taking care of ourselves means losing patience with others. Probably because I don't define "patience" as meaning doing things for people that they could/should do for themselves, I find that we can learn to set limits/boundaries quite patiently--albeit firmly: It's called "assertiveness." What tends to happen here--and here is where the "more forcefully" part comes in--is that people who are used to you saying "yes" all the time won't like it when you start saying "no." You are violating the unspoken contract you've always operated on with them (this is true of society as a whole, too, by the way). So they will tend to ask again, and again, or ask more forcefully, or start trying to guilt-trip you (see the discussion on bitchiness, below). And then sometimes we lose our patience with them (and start yelling, "What is it about 'no' that you don't understand? Read my lips! NO!!"). This is, as my mother would say, "not attractive."

So here's where the patience part comes in. We have to remember that, human nature being what it is, people are going to resist change in us. If we see resistance, that actually means we are doing something right--that is to say, we are changing, and people are noticing. That is a Good Thing. And we have to remember that we are teaching them something new about us in particular and about the world around them in general, and that takes time. One-trial learning is not going to happen here.

And saying "no" in and of itself doesn't really make us "meanies", either. Men say "no" all the time, unfortunately women aren't supposed to. We will be perceived as meanies if we are assertive about our limits and boundaries, but it is not the same. Years and years ago (back before the Flood, but never mind--I digress) there was an article in Working Woman magazine on the subject of bitchiness. And the author wrote that "bitch" stands for "being in total control of herself". It's a socio-cultural gender thing. It's also a grand manipulation: People individually, and our culture as a whole, both use the B-word on us when they are not getting their way. It's intended to shame us into caving in to whatever it is they are wanting at the moment, or in society's case, into not demanding whatever we are demanding at the moment. It's about some other person or institution or other kind of group taking control back from us.

(By the way, you can't allow that to happen. In terms of the teaching process, it will set you way back with that particular individual/group/institution. You have to be consistent, persistent.)

But getting back to where we were, I believe that what does make us meanies is when we say "yes" and then resent the hell out of it later, becoming cranky or passive-aggressive, or worse, both. Crazy's right-on in perceiving that saying "yes" when you mean "no" is a prescription for angry outbursts and/or building resentments. A trick I learned for avoiding that is to (a) try not to answer one way or the other right away--ask the requester for time to think about it, put 'em on hold, whatever you have to do to buy yourself some time, and (b) when I've already said "yes" and realized that was a mistake, to go back to the requester and say, "I spoke too soon when I told you I would [whatever].... Sorry, won't be able to do that after all. Nope. Not gonna happen. No, sirree." It's bad form, not to say awkward, but it beats being mad or resentful, and you won't have to do it too many times before you learn not to say "yes" in the first place!

And Crazy is also correct that learning to say "no" without biting people's heads off requires practice. I therefore sometimes advise people, just for practice, to say "yes" to three things that they would ordinarily deny themselves, and "no" to three people they would normally accede to, per week until they get the hang of this. Learning how to do this, and do it well, is, as Crazy says, "kind of awesome."

Saturday, January 3, 2009

Wounded

Untitled: © Irina Sidorowicz - Visit NoHappy.com to see additional artwork and photography. The artist studies Graphic Design and Visual Communication in Buenos Aires.

This picture, posted as a writing prompt at Every Picture Tells a Story is powerfully evocative for me. My first reaction was that she is Palestinian, but she quickly became bigger than that. She is Afghan, too, married at ten or eleven to a man decades older than she. Then she became all wounded women.

Inside every battered woman, every woman who was sexually abused as a child, every rape survivor, lives a girl-woman like this. However bright and strong and confident she may look on the outside, and they do, this wounded girl-woman looks out from behind her eyes. I may see a flicker in the first session, or I may not catch a glimpse until she's been here a few times.

If I can earn her trust, sometimes she will come out.

Thursday, January 1, 2009

Reassigned Time: 2009 Here I Come - Resolutions

In Dr. Crazy's post, Reassigned Time: 2009 Here I Come - Resolutions, she points out the importance of not only (1) making resolutions that are achievable, and (2) thinking of them more as goals than as resolutions, but most important of all, (3) thinking of each resolution as a favor you are doing yourself which you have earned and deserve. She writes:
...when Things happen, the first thing to suffer is me. Working out, or eating well, or taking time to relax, or getting enough sleep, or whatever, well, that has been the first thing I've dropped throughout the history of me. ...when I drop me, in my head it's a present to myself .... A mountain of overdue grading vs. cooking dinner? ...I have to do the grading whatever the case, and so don't I "deserve" not to go to the gym, which I do not enjoy? ... It's easy to let myself go. I like it. Partly because the ways in which I typically let myself go are quite enjoyable. I mean, who doesn't like to eat food that's bad for one...I've typically characterized "self-care" things as the antithesis of things that will make me happy or that will make any material difference in my life. ...

... I totally need to shift my perception of what it means to take care of myself. ... to think about it less as a chore and more as a reward. I've accomplished so much in the past 10 years. ...And so why not think of focusing on me ... as the reward? Why exactly is it that I've convinced myself that cooking dinner isn't something that's "important" compared to other tasks on the to-do list?

I need to take care of myself ... first. Period. Like as a non-negotiable thing. ...not as "extras" that can be let go, or as chores that need to be done, but as just normal, everyday things that make me happy and that are just part of my life.
Which is why, without realizing it, I made some of the resolutions I did. They are all things I do anyway, like walk the dog and take pictures, that I simply want to do more of because they make me happy. So they are (1) totally achievable. They also aren't really resolutions, in the sense that people, for example, typically resolve to stop smoking or lose ten pounds. I don't know whether that makes them (2) goals or not, but I have found that it makes all the difference in the world if you put your resolutions/goals/whatever in positive terms. In other words, belay the stops and nots and loses.

The key for me, as I suspect is true for most (if not all) of us, is not to let any of my goals go by the wayside because something presumably more important comes up. I like Crazy's new point of view that she's already earned the right to treat herself well, that she's already paid her dues. She doesn't have to do the grading before she can let herself fix a nice dinner: That's already bought and paid for.

So here goes (3): I have done a heckuva lot already in this lifetime. I have earned four degrees--count 'em, four--married, established a household, bred Boykins, raised a son, established a practice, employed some people, thereby enabling them to make a living, supervised some people all the way to full licensure, taught some kids a few things, helped some patients, been a good friend to a few good women, adopted two birds and a dog (we adopted the child, too, but it is different) and probably more in my 56 years if I thought about it longer. I deserve to take more photographs, walk more dog, laugh more, love more, live more.

And so do you.

New Year's Resolutions

  1. Take more photographs
  2. Watch more birds
  3. Walk more dog
  4. Laugh more
  5. Write more
  6. Take more time off
  7. Love more
  8. Live more

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