Preventative Model and Psychopathy Among Other Weird Noms

I'm still reading Frances's book.  Slowly taking it apart, and all that.  I admit it, I'm not all that quick-witted.  It takes me a while to mull through a concept.  Neurotic perhaps, and dull maybe, but that's who I am and what I've got to work with.

Something Frances said in his Saving Normal is bothering me a little bit.  The preventative health care model is supposed to save lives.  It's supposed to reduce the cost of treatment, but it often has the opposite effect according to him and others.  There is empirical support for his view.  Applying unneeded testing, and making those tests sensitive enough that they dragnet great swaths of humanity that doesn't suffer from disease, and never will is a costly endeavor.  I think it's built on the social need to eradicate disease before it threatens the entire population.  Obesity is one great big example (no pun intended) of this concept.

Most people will find a happy medium through exercise and diet, although there is a propensity for umami (fatty foods) and salt.  These are obvious proclivities when evolution has designed a desire to keep and hold resources for later use.  Obesity is that very drive taken to an extreme, but testing for obesity and aggressively treating it is causing a great deal of harm, and not just within the realm of medical treatment.

The current President of the APA, Dr. Bennett Johnson, called obesity the disease "that is going to bankrupt our country."  How is this appropriate?  Fat jokes are already a problem, ala bullying on schoolyards, and a thousand other places, including college campuses, and college classrooms, e.g. NYU prof Geoffrey Miller.  Fat shaming is a problem that produces more pathology than it does healthy behaviors.  So why this aggressive stance?

In the medical model, as I like to use my personal experiences from time to time, when my wife was unfortunately the owner of a fairly large ovarian cyst, we have staples, bands, and other treatments that aren't just aggressive but dangerous to combat this social ill.  In the waiting room of the surgeon who (thankfully) removed the tumor, but also (irresponsibly) removed my wife's staples too early and thus caused a gaping, permanent scar and high probability of infection that could have proved fatal there were always women discussing how their gastric band had unintended consequences.

At one point do the risks outweigh the benefit, and aren't we far beyond that point in the US?  What has the preventative model earned us on the front in the war against obesity?  Our society seems focused on using inappropriately risky and often harmful methods instead of focusing on preventative measures that: a) are proven to work, b) are cheap to produce, and c) are tempered by reasonable expectations of outcomes.

The suggestion that the market will be there, and the bullying will be there, doesn't save my wife's surgeon, or Dr. Bennett Johnson from scrutiny.  In so many areas, even in known cancer risks like smoking, aggressively treating the disease is causing more harm in anti-social attitudes, reaction formation, and prejudice than it is producing desirable results.

Using smoking as an example may be taking this argument too far, but it does make the point rather well.  Much like the War On Drugs, and Nancy Reagan's "Just Say No" policy, and aggressive social campaign, it proved to be ineffective, costly, and produced the opposite outcome from the desired result.  It was a joke.  A laugh.  A reason to smoke pot, not a reason against it.

Preventative strategies often mask deeper attitudes that direct behavior.  Much like the war on drugs, and the war on smoking, I believe that there is a puritanical philosophy that drives the fear, and mistrust of liberal, democratic values.  The authoritarian personality is a prime example of this notion of the Prodestant Ethic: that one treasure's one's body as a gift of god, works hard, offers fealty to authority, and does not question the nature of things or the consequences of the social order.

I think that preventative medicine is very much like giving an island to lepers and then letting them die off slowly.  It reduces personal responsibility toward the collective, rationalizes a just world hypothesis, and feeds racist and prejudiced attitudes.  Lest we forget the Iraq debacle, prevention is often practiced against ghost-like problems that match symptoms but do not match degrees and do not define prognosis.

And while we're discussing prognosis, let's consider psychopathy.  There was a time when, in the disease model, that a disease was defined by it's prognosis meaning that what one could expect to occur defined a disease, or a disease was the product of it's outcome, not it's symptoms.  Symptoms are the visible signs of disease but they are not, themselves the prognosis (or what will occur).

Considering the difference between secondary and primary psychopathy the formation of symptoms is not the only difference.  The difference lies also in prognosis.  Wherein secondary psychopathy one can expect a degree of self-healing given the right amount of time and circumstance, the same cannot be said of primary psychopathy, yet they are considered the same disease with merely like symptoms.  This, I think, was the rationale behind adding antisocial personality disorder to the DSM.  But by not including psychopathy in the DSM the differentiation never occurred even though, in this one case, we know that epigenetic expression of a particular gene, mono amide oxidase or MAOA is the cause.

Primary psychopathy and secondary psychopathy (APD) are different diseases because their prognosis, and their constructs are different even if they share some like symptoms.  It seems lazy to me to not define it such when the tools are available, through even something as simple as an interview is capable of defining the difference between the two.  Nevertheless, in APD, and Bipolar, among others, we have these overlaps of several different individuals with different diseases with different causes and different prognosis all lumped in the same boat together as one massive whole that society would really enjoy throwing down a completely different hole (now that was a pun).

This type of lumping is irresponsible where diagnosis defines treatment, and social stigma is very real even inside therapy sessions.  Therapists are, after all, people, and subject to the same bias, and projective tendencies as the rest of us.  These tendencies, are, however, forgotten.  Chalked up to evidenced behaviors even though they exist inside the system of perceptions of the patient.  Yes, therapists and doctors, you cannot help but act in a particular way once you've labeled your patient which demands certain characteristics from your client.  Voila', we have yet another suggestible, but normal patient diagnosed and lumped in a box by yet another suggestible, but well trained therapist.  And no one is paying attention.

Marvelous.

These two problems, although they seem distant, feed into each other to create bias.  Frances's concept of diagnostic creep, and the problems inherent in preventative care have produced a situation that does not serve patients or normals.  These situations serve several bottom lines.  Not just big pharma.

What's the Point?

I've been playing around with the NPI because I'm concerned about a few things.  I'm concerned because some of my behavior, according to a few of my acquaintances seems narcissistic.  The problem is that when I'm honest in how I feel about the questions, I score consistently between either a 1 or a 4 depending on whether I'm feeling particularly grandiose.  I even lied and garnered a score of 10.

How then, assuming that the NPI has external validity (if I got that right), am I narcissistic?  I just don't get it. I do play up to people's expectations.  I admit that.  Being male one almost has to.  Part of being a leader in any fashion is being thoughtful of the expectations of others and maintaining their opinion.  Doing so ethically is defining one's actions by the consequences for not just oneself but others.  I don't always get to be me, or do what would be best for me.  That's part of life, and a natural part of being a leader.

As an example, I don't get to abuse my authority.  I have to earn it, and keep on earning it day after day.  But at the same time, those who are most likely to term me narcissistic, have more authority, and I do challenge them on particular points where I think they're wrong.  I don't think challenging authority necessarily qualifies one as narcissistic whether or not the DSM defines it as a characteristic of a narcissistic personality.  Where status is concerned, those who seek it are those who abuse it, and I'm well aware of that and I think they are too.

Nevertheless, I do think I haven't been genuinely myself.  Not for a long time.  I refuse to bow to whimsy, or what I consider to be ill-thought conclusions with more harmful consequences.  Thinking about, "how do I fit inside these structures" never seems to happen.  Perhaps those thoughts have already occurred, and yet, to ask a question once and deduce an answer isn't wise.  Knowledge, and wisdom, come from asking the same questions over and over, and sometimes receiving different answers, then testing those answers both mentally and experimentally.

Why am I the only one that seems to see this?  Because of my position, perhaps?  That I have to prove it?  Maybe.  Those who are identified as ethical are more likely to abuse their authority.  I can't remember the researchers who tested that hypothesis.  I never should have sold my Social Psych text.

So, what's the point of reaching new heights when socialization structures replace my questioning with assurance that I know what I'm doing and stop questioning?  I don't want to be the asshole who makes life more difficult for everyone, including me.  (see productivity experimentation and theory)  But is that who I must become?  A narcissist?  A fool?  A fat bureaucrat sure of his own righteousness?

I think I'll stick to teasing out my own understanding.

And Another Thing: The Course of Disease

Why are there no books on the course of disease among the mentally ill?  This would seem to me to be absolutely necessary, to establish the epidemiology of a particular disorder.  So, why no interest in following the course of a disease to define an accurate prognosis?

Are we so sure of our affect that it is, by rights, disengaged from consequences as compared to the natural course of a disease?  What does this say of our collective hubris?  What does it say with regard to the consequences of our actions?

Can we say that what we're doing in the US in our push toward pathologizing, and treating larger and larger swaths of the public is both necessary, and has a desirable outcome.  What does this say about the surge in plastic surgery?  Is a consumerist demand the only test?

This seems more than foolish.  This seems to lack any conversation with, or about, the consequences of societies actions, or the specific actions of health care professionals.

Where, in all of medical training, are these ideas?

Rule of Thirds

I've been reading (so what else is new) and finally ran across Hippocrates rule of thirds as explained in Frances's book, and, put simply, I'm vaguely concerned.

Why thirds?

As a short explanation of the concept: Hippocrates believed that prognosis was a vital skill that physicians had to develop.  Part of prognosis was determining who could get value from care. He broke patients down into three categories: 1) those who would get better on their own, 2) those who could benefit from treatment, and 3) those who would never get better.

Presumably this set of standards was to prevent the loss of resources treating those who would eventually get better on their own, or those who would never get better.  Ideally only those who could benefit from care would receive it.  One of the questions that immediately springs to mind, among others, is "Who decides?"

In what way does bias feed into this game of thirds?  It's really a simple question, but it means a great deal to people who suffer from disease, particularly mental disease.  The bright lines between needing medical help, and too far gone to do anything for don't exist, including those between able to heal on one's own and needing medical or psychological attention.  All these decisions, to make them more difficult, exist withing the social structures that we are all very much aware of.

What's to ensure a man of African descent will be treated with equal consideration?  Or a woman?  Or a man?  Where does personal judgement conflict with an ethic of equality, particularly within a system so severely skewed by  not just personal, but societal bias?

I have too many questions.  What I don't have is answers, and maybe that's appropriate.  Having an answer, a defined system of consequences offers assurances that what one is doing is right.  It makes it easier to make decisions that affect people's lives, whether or not those systems of ethics truly reflect the world as it is.

Normal, Anyone?

I've been reading Allen Frances's new book, Saving Normal.  In it I ran across a simplified discussion of something that's been bothering me for some time.  During my investigation of psychology, even in my earliest understandings, there has always been the concentration on the pathological.  Much like Seligman's appraisal in his TED talk, a focus on pathology leaves quite a bit to be desired, particularly when the definition of health, or even normal is undefined.

So, what is normal?  That's one of the questions that Frances asks, as well as Seligman and notable others.  Frances makes the point that the WHO definition is an impossible perfection.  No one is without even the barest of hints of disease, maladaption, or strain.  Such perfect contentment is fleeting if it ever does happen, and represents that which will ruin society as a whole.

This focus on perfect health, and personal responsibility for one's emotions is tantamount to enslavement, and I'll tell you why.  Even when one's life circumstances are so dire, and unchangeable, the presumption is that the mind is free enough to soothe the pangs.  Under this logic, victims of rape, torture, abuse, neglect are all not just victims, but victims of their own making.  It's the just world hypothesis at work in its most insidious manner.  Taken to its logical conclusion, no trauma rationalizes debility, therefore no debility is to be expected even in egregious circumstance.

The current trend of therapies toward fixing cognitive fallacies, though necessary, capitalize on precisely these belief structures that dangle out from the edges of trauma.  Ellis was particularly ignoble in this regard, and in my mind so are his intellectual kin.  Bowen's meta-systems theory is only slightly better.  Without defining what's normal, and by extension what's to be expected inside the systems an individual represents, how can anyone hope to treat the individual swaddled by those same systems?

What's more, without defining health to a reasonable degree, analysts, therapists and researchers are swayed by cultural artifacts that direct not only their behavior, but the behavior, and lives of their clients as well.  Perhaps Rogers was wrong about one thing (and probably more),  that the "client" appellation would be good for the development of a relationship as a whole.  It makes it easier for therapists and clients to join, this is true, but it also reduces the responsibility of the therapist in the situation.  But then, with regard to Piff's recent studies on social class, perhaps Rogers was right, and didn't go far enough.  Perhaps it's the "father knows best" attitude that drives a wedge between client and therapist and feeds a cavalier attitude toward what is essentially the "other."

CBT, and REBT does have value.  I'm certainly not saying that it's worthless.  Several studies have shown substantial effect sizes.  However, it isn't the cure-all that some claim it to be, and it certainly isn't 16-week-savior it's often made out to be.  Situational influences are very real, and commanding.

A person who works for minimum wage is never going to be wholly functional.  And, it's very important to remember, perfect functionality is akin to psychopathology.  There are some areas of life, and living, where it's perfectly reasonable, and desirable to be less than functional.  In committing murder is only one extreme example.

Defining health, and defining normal, in my mind, should have been the first tasks of psychology instead of at, or near the last.  But then, we simply don't pay attention to what's normal.  It's part of what makes us what we are.

I still haven't figured it out.  What the hell is normal?

Where Consumerism Meets Medication

Dire Constraint and Work

In law, dire constraint represents the basic concept of a mugging when discussing a contract wherein the situation is the prime determinant of the validity of a contract.  At this point we can start asking questions.  One group of those questions has to discuss the limits of a reasonable expectation of rationality where work is concerned.

Work, as we know it today, is a little different from what it was in the past.  At one time an employment contract included those unwritten rules of conduct that defined decent treatment of an individual employee.  These unwritten rules were expanded on in writing through the FLSA (the Fair Labor Standards Act).  But can we say that the FLSA went far enough?

Let's consider one situation where the FLSA may apply, and see if it does apply:

Let's take, for example, a theoretical woman entering the job market at a low wage employer.  Without a work history, and without access to resources to afford, even in debt, the basic contributions to her own transportation to and from work.  Let's say that she uses community resources in the form of loans to afford that transit to her position at a fixed place of business, perhaps a restaurant.

Let's say she performs beyond expectations in her position.  Completes all required training at the place of business where she is employed.  Let's then say that her employers require her to travel 50 miles one way to a training seminar that is only available for one day, which her employers notify her of that same day.  She cannot afford the trip to the external training site as she makes minimum wage.  All her wages go to surviving long enough to return to work.  The employer nevertheless imposes the threat of terminating her employment if she does not attend the seminar.

FLSA only states that an employer is required to pay for time in training.  It does not state that time in transit need be paid, nor does it provide for renumeration within such a small journey, nor does it suggest that she be compensated for travel expenses, nor does it require a time frame short enough to defer the actual cost.  Nevertheless, the scenario presents a dire constraint.  The figurative gun to her head is the loss of her low wage job.  Their coercive tactics are unlawful even if they are not spelled out within the FLSA or other state or federal law.

There is a trend growing in this country.  A derision of laborers, and an alignment of work-for-pay as a system of fealty.  As if workers were feudal vassals, expected to defend the honor, and the profitability of the company for which they work or else.

At what point are we going to say, "This qualifies as dire constraint.  The threat is real, and was communicated by an agent of the company.  No such contract can be enforced and damages should be levied"?

Are there circumstances that require termination of contract?  Yes, there obviously are.  But to suggest that a person who works for minimum wage can effectively defend their own interests against a multinational conglomerate is ludicrous.  Law should err on the side of the employee who has the least resources and can bring to bear the least able defense.  Nevertheless, in this country might now makes right.  If they can physically force an employee to do something, or do so by merely threatening their employment opportunity, then they may.

How is that in any way freedom?  As if freedom to choose one's Machiavellian master is a freedom at all.  It is a false choice and thus no contractual obligations can be enforced.

At what point did America become the corporate state?  Was I asleep when corporate interests were handed a figurative gun and the permission to use it as they will?  Was I gone when the law became something other than a system of negotiation to normalize relations between two parties?

Normalizing relations, in America, now means handing the criminals the keys to their cages and arming them with the tools to perform their crimes.  No wonder rape is such a problem here.  Exploitation, connivance, and coercion are part of our culture now.

It is a culture I do not like, and will always fight against to the best of my ability.