My Capstone Files

The function of hemispheric asymmetry in regards to perceptions, cognition, and emotions.

Introduction
The intent of this capstone project is to study the hemispheric-specific traits of the brain to identify how these traits affect perception, cognition, and emotion. It is hypothesized that a counselor could theoretically increase rapport with their client by having a greater understanding of how the brain affects the mind. To determine whether this idea has any possible scientific basis, a literary review of professional books and journal articles dealing with brain hemispheres and mental functions was conducted. Research was focused on perception, cognition, emotion, concept of self and ways to identity hemispheric dominance. Personality was also an aspect originally considered, but none of the literature reviewed made any reference to it.

Main Paper
Tables

Conclusions
The hemispheres take on many hats as they work together, outside of the commonly repeated visuospatial and verbal ones. In regards to perception, the left hemisphere acts as a reporter, keeping an ear out for language patterns and detailed information. It looks for past occurrences and hints to future events. The right hemisphere acts as a sentry, constantly scanning the surroundings and looking for anomalies that may signal a threat to the body. Aware of the present moment, it notes distances and forms. When it comes to cognition, the left hemisphere is a bricklayer, breaking down information into smaller parts and arranging it into analytical series. Where gaps appear, the left will cover them with its own version of mental mortar. The right hemisphere acts as a project manager, on alert for mistakes and incongruities, while calculating the relationships of the elements involved. In memory, the right hemisphere cues the left hemisphere with generalities, so it can retrieve memories and link them in sequential order. Emotionally, the left hemisphere relies on the past to guide it, using the models and scripts it has created. While the right hemisphere focuses more on current physical and emotional sensations.

In regards to helping counselors relate to their clients better, this data won’t necessarily lead to a better therapeutic alliance. However, there are other ideas that counselors can take from this information to help their clients. Dr. Taylor’s recovery from her stroke shows how controlling one’s emotional environment can help their psychological well-being. Another lesson from her experience that has not been mentioned here yet, is the fact that when her left brain began to recover some of its scripts, she made a conscious effort not to let the negative ones reassert themselves. Her gestalt therapist probably deserves some credit for this, but it is obvious that the ability to say, “this is just my brain trying to do its thing,” did her a lot of good. When Dr. Taylor finds herself in a mental loop that is harshly critical, counter-productive, or out of control, she gives herself 90 seconds to let the emotional/physical response dissipate before re-evaluating the situation and acting. (Taylor, 2007) Being able to give some clients this self-knowledge might enable them to work with their mental processes, instead of fighting them in unproductive ways.

There is obviously a need for further study in this area. For instance, it is possible that learning styles may positively impact the therapeutic alliance, but the field needs more valid tests and research. The idea that false memories can be detected needs to be tracked longitudinally to check for the effects of memory fading. In the areas of depression, anxiety, and BDD, researchers are only scratching the surface. It would be very interesting to see if training techniques that help stroke victims would also help people with these disabilities.


References

Learning from primitive cultures

In my last post, the second video I embedded by Gever Tulley mentioned how the Inuits taught their children how to use knives at a very young age, thus allowing them to gain better control of a basic tool of their life. In my foundations of sociology class, I had the opportunity to read and critique a wonderful article by Richard Sorenson on the Fore culture, which had some amazing cultural social stucture.

I like the TED.com talks, because they give me a way to share ideas without totally bogging people down with my wordiness. I had thought I had found an excellent talk about documenting endangered cultures; however, while the efforts shown are commendable, I truly feel that the speaker is missing out on the real lost of these cultures. It's good to know that there are other cultures and other ways of doing things, but we also need to save the lessons of life from these culture and learn from their social structure. We obvioiusly can't apply everything we learn and some of it we may not want to, but some cultures can give us wonderful examples on how to deal with others and life.

So, instead of treating you to a video (which you can find here on TED.com), I will instead give you my critique of Sorenson's article. Yes, I'm lazy when it comes to repeating information, but my friends already know that.

CRITIQUE
A Doerr
April 3, 2008

Growing Up as a Fore Is to Be “In Touch” and Free (from Readings for Sociology)

The thesis of Richard Sorenson is that the reduction of cultural diversity may rob us of some very important knowledge and influences. He bases this on his observations of the Fore people in Papua New Guinea. It is obvious that he considers their original cultural to be a utopia of human interaction and child rearing. His downplaying of the fact these people have patterns of settling and then migrating when the land no longer can support them shows a willingness to overlook the fact that if the survival rate of the people improved, they would have eventually developed like many other ancient cultures who found that with success comes an increase in structure.

However, his point that we would do well to record these cultures before they become “corrupted” by Westernization, is a very valid one. Knowledge and skill can just as easily be lost as gained when a culture changes. Art professors have commented that their students no longer have the fine skills the artists of previous generations did because they no longer have to do as much by hand. By knowing what we have lost, it is possible to perhaps relearn it or at least modify it to work to our own cultural benefit. In the case of the Fore, the most precious knowledge would be that on how to raise confident and wise children with few emotional problems.

Sorenson’s article also shows how quickly a culture can be changed when it is naturally inquisitive and opened to ideas. Indeed, he states that this was the downfall of the Fore culture. Something as simple as a road can make a great deal of difference. But his article shows a lot more than just that. It shows how people in primitive cultures actually have comparable intelligence and mental sophistication to be able to adapt to a more industrial way of life if they are open to the concept, belying the ideas of inferior races. It shows how rushed cultural changes can “toss the baby out with the bath water”, suggesting that we would do well to revisit our own cultural pasts to see what we have left behind.

This article is worth keeping in any family counselor’s personal library. While the Fore culture can never be regained in this world, there is enough there that may help us sort out dysfunctions in our own family relationships. In the end, Sorenson’s point about learning about primitive cultures before they are lost, is more than aptly made.


I know, it would probably be more helpful if I directly quoted from the article. If you are really curious, you can read some of Sorenson's work here. It's not the same article I critiqued, but it covers some of the same data.

Left Brain/Right Brain Components of Art

Cutting and pasting part of the capstone paper again. ;)

Perception in the left hemisphere.
If there are two words that describe how the left hemisphere perceives the world, those words are "details" and "boundaries". This might be explained by the fact that, while the ears and eyes send data to both hemispheres, the left brain hears the higher frequencies of sound and sees the shorter wavelengths of light. The higher frequencies of sounds helps the left hemisphere to distinguish vocalizations and language sounds, the sounds that the speech areas of the brain need to interpret. The shorter wavelengths of light helps to show lines, edges, and boundaries. (Taylor, 2006) Dr. Howard Sachs, a retired neurologist, decided to continue doing art after he suffered a stroke to his right hemisphere. The following image of his art shows some of the typical traits of artwork done by the left hemisphere: many details, but poor proportions, spatial relationships and overall coherence. (Springer & Deutsch, 1998)

Painting by Dr. Howard Sachs, MD. PhD. Used with permission.

In a very real sense, the left hemisphere cannot see the forest for the trees. While it focuses on details, it does not keep track of the relationships between those details. Relational data is often fuzzy, something that it is not well equipped to deal with. The left hemisphere tells us the boundaries of our environment and the boundaries of our own bodies. (Taylor, 2006). Ironically, it pays the most attention to the right side of the body, sometimes causing a degree of attention neglect to parts (and even the environment) on the left. (Springer & Deutsch, 1998)


Perception in the right hemisphere.
The two words that describe how the right hemisphere perceives the world are "novelty" and "global". The right brain hears the lower frequencies of sound and sees the longer wavelengths of light. The lower frequencies of sounds helps the right hemisphere to distinguish bodily and nature sounds, such as intestinal gurgling and thunder. The longer wavelengths of light blurs lines and edges, making areas and the relationships between them more obvious. (Taylor, 2006) An example of this is Edvard Munch’s painting, The Scream, which shows some of the typical traits of artwork done by the right hemisphere. If we ignore the deliberate distortion of the main subject, we can tell that the perspective and spatial relationships are accurate, with sparse details. (Springer & Deutsch, 1998)

The Scream by Edvard Munch (1893).

An interesting side-note: when Dr. Jill Bolte Taylor (2006) was recovering from her left hemisphere stroke, she didn’t give any consideration to colors until her mother pointed them out to her. This could be considered just a case study anomaly, except for the fact that anthropologists and linguists studying color have noted that the more primitive the culture, the less colors they will have names for among the general populace. Berlin and Kay's (as cited in Gates, 1999) evolution of linguistic development, in regards to color, states that there are seven stages of color recognition: from black and white to black, white, red, green, yellow, blue, brown, purple, pink, orange and grey. More recent studies show that Western civilization has around twelve colors in common usage, in addition to various colors that come and go as fashion dictates. In every culture, artisans will recognize and name more colors than the normal populace because the distinctions are useful to them. (Gage, 1999) It would appear that while the right hemisphere can see colors, it takes the left hemisphere to find a use for them and give them consideration.

Cooperation between the hemispheres.
Most of the tasks done by the brain require input from both hemispheres. The ears, eyes, and sense of touch send signals to both sides, though the signals are stronger for the hemisphere opposite of them. To help the brain adjust to possible injury, each hemisphere can do many of the same tasks, but in their own way. One of the problems that researchers face is the fact that hemispheres are so adept at covering for the other that it can make narrowing in on significant differences difficult. Both Dr. Taylor (2006) and Dr. Sachs (2008) were able to recover some of their damaged hemisphere’s functions through the training of the other hemisphere. Five years after Dr. Taylor’s stroke, she was able to do division and other simple mathematical problems. Two years after that, she was teaching Gross Anatomy again. As of 2006, she was a consulting neuroanatomist at the Midwest Proton Radiotherapy Institute, helping stroke survivors neurologically rehabilitate themselves. (Taylor, 2006) Dr. Sachs, in his 80s, is retired and living in an assisted living center. Even though it takes lots of concentration on his part, he still paints on occasion. He is fascinated by the lines and furrows of his fellow resident’s faces, though they will not sit for him. Here is another painting by Dr. Sachs in which the defects of his right hemisphere injury are not as apparent:


Painting by Dr. Howard Sachs. Used with permission.

When there isn’t an injury, there are many times symmetrical responses in the hemispheres while doing tasks, even if one side initiates the task first. It is through the process of "cross-cuing" that the hemispheres share information with each other. However, not every task gets originally sent to the hemisphere best suited to perform it, though the hemisphere always performs the task consistent with its own style. Some studies suggest that the mental task to be performed is usually more important than the nature of the stimulus when it comes to hemisphere selection. (Springer & Deutsch, 1998)

Resources
Gage, J. (1999). Color and meaning: art, science, and symbolism. Berkeley : University of California Press.
Sachs, H. (2008, August). Drawing from the left side of your brain. Howard's Weblog. Retrieved May 21, 2009, from http://hmsachs.wordpress.com/2008/08/25/drawing-from-the-left-side-of-your-brain/
Springer, S. P. & Deutsch, G. (1998). Left brain, right brain: perspectives from cognitive neuroscience. 5th ed. New York : W. H. Freeman and Company.
Taylor, J. B. (2006). My stroke of insight: a brain scientist’s personal journal. New York : Viking.

art therapy in prison

Creating Safer Prisons Through Art
By Amanda Doerr

Originally written April 24, 2007

The first questions many people have in regards to art in prison are probably along the lines of: “Why should we make life easier for these convicts?” “They’ve broken laws and now we’re going to let them play?” “Why should our taxes go for such a program, when there is so many other things we could fund?”

The best answer to these questions comes from Ed Howe, the activities manager at the State Correctional Institution Pittsburgh, who says "[Art] also keeps us safe. If prisoners have idle time, they find their own recreation." (Menees, 2001) This is not a good idea by any stretch of the imagination. If some of these people had healthy outlets for their boredom, they would not be incarcerated in the first place. They are in prison because they are unable to function in a conventional social environment. (Gussak, 1997, p 1) Case in point, convict Jeremy Pinson spent his time in prison planning revenge and writing threatening letters because he didn't have anything else to do, adding more and more time to his own prison sentence with each threat he mailed. (M. G. Preisz, Oklahoma City University Forensic Psychology lecture, April 17, 2007) This is not an isolated incident. The Commission on Safety and Abuse in America's Prisons also found in their research that "few conditions compromise safety more than idleness." (The Commission on Safety and Abuse in America’s Prisons. [CSAAP], 2006, p 14)

Art's effect on violence

Can art actually affect the level of violence? According to the 1983 California's Brewster Study, inmates participating in AIC [Arts In Corrections] at two state prisons had fewer disciplinary problems. (Menees) In one institution, the reduction of disciplinary reports written was 80%. (Gussak, p xix) How much violence could art reduce nationwide? Unfortunately, not enough data about non-lethal violence is available to properly assess the costs of violence to the prison system. Some facilities keep no record at all of the assaults within their walls. (CSAAP, p 15)

Art can help in several ways. Crafts often build self-control within inmates, even those uncomfortable with drawing and painting. (Hall, 1997, p 32 and Milligan, 1997, p 181) Creating expressive art can help an inmate avoid a confrontation by giving him a way to work out his anger. (Hall, p 33) If the means are available and conditions favorable, aggression can be channeled through the creation of physically demanding three-dimensional objects. (Ronaldson, 1997, p 179) Releasing emotion can be problematic in a prison environment, for it can either be considered threatening or a sign of weakness to both guards and other inmates. Inmates who engage in art making are less disruptive, having less of a reason to act out. (Hall, p 39) This was true whether the art was created in an art class or in isolation in a cell. (Taylor, 1997, p 200)

Art also works with mentally ill inmates. Board Certified Art Therapist, David Gussak, one of the editors of Drawing Time: Art Therapy in Prisons and Other Institutional Settings, has "seen examples of nearly every DSM IV diagnosis" while working with prison populations. (Gussak, p xv) The sad reality is that there are still people being sent to high security prisons, who pose no threat to the populace, simply because they are mentally ill. (CSAAP, p 16) Art is a powerful tool for dealing with depressive symptoms while incarcerated, though not as much anxiety symptoms, possibly because heighten states of anxiety are needed for survival in prison. Still, art helps the mentally ill inmate cope better with his situation. (Woodall, 1997, p 116)

Making art safely

There are no total guarantees in life, not even with art. Safety must still be maintained. Scissors, long pencils and paintbrushes can be weapons in the hands of a determined inmate. Clay can be used to make a key or disable a lock. For these reasons, many normal art making supplies are not allowed inside many prisons. (Ursprung, 1997, p 18) Even common art solvents such as turpentine can be forbidden because of the potential risk they can pose. (Menees) Art therapists and facilitators in prisons have discovered many alternative sources of art supplies, often through the ingenuity of those under their care. Found art is common, but other art media might include: foil potato chip bags, socks, hair, nuts, Kool-aid and M&M candies as pigments, magazines, cigarette wrappers and a mixture of toilet paper and soap, which when "mixed with water and combined in the right consistency" becomes a modeling paste that can easily be painted. (Ursprung, p 19 & 21) One inmate grew his hair for five months in order to make his own paintbrushes. (Dobnick, 2006) Through much of the literature on this subject, the need to create in a hostile environment is commented on again and again. (Ursprung, p 17)

And on their own, therapists and facilitators come up with ways around the restrictions. While making masks is usually prohibited because they might aid in an escape, Gussak's solution was to have the inmates make masks with paper plates that couldn't possibly resemble a real face, thereby allowing him to still use a very powerful art therapy technique. (Gussak, p 69) He also taught the inmates to create Plaster of Paris three dimensional works that not only could be accounted for after the session (thus satisfying the fear that it would be used on keys and locks), but also created an art experience in which inmates had no expectations of seeing a recognizable form in, eliminating feelings of inadequacy based on their art skills in most of those participating. (Gussak, p 63)

Even when normal art supplies aren't used for dangerous purposes, care must be taken so they won't be stolen. Art supplies are a valuable commodity in the prison black market because they are means to earn goods and services from other inmates. Portraits, handmade stationary, posters, and decorative objects are often purchased as gifts for loved ones on the outside and for personal use. (Hall, p 36 & 37)

Art and guards

The relationship between guard and inmate depends on a great many variables, not the least of which is the managing culture of the prison they are in. Because of their duties, prison guards and other staff can and do affect how art is created in their institutions. They can't stop it completely, but they can help or impede its creation.

Positive staff involvement can bring about significant results in a prison arts program. It can even generate inmate sympathy towards the correctional officers, as evidenced by an inmate at Folsom State Prison, who said that even the guards didn't need any more negative publicity. Even as far back as 1930s, the connection between the guard and the guarded can be shown, when "a convict named Ralph Pekor painted 'The Last Supper' in the prison chapel . . . The warden loved the fresco until he realized the convict had painted him as Jesus, the inmates on condemned row as the disciples, and, for good measure, tucked himself in underneath the table." (Menees)

Jung once said "The meeting of two personalities is like the contact of two chemical substances. If there is any reaction, both are transformed." Whether this transformation is a positive or negative one depends on the correctional staff more than the prisoners, since they, by their position, hold most of the cards. In a positive manner, staff may become involved through helping in the display artwork in shows that help breakdown the stereotypes of incarcerated people. (Ursprung, p 15) In addition, prison staff may buy inmate artwork, allowing their own prejudices to be dispelled through the admiration of the creative works and giving the inmates a means for purchasing more art supplies. (Ursprung, p 21) The effects of this transformation can be far reaching, even across generations. A Sing Sing guard who encouraged and helped an inmate artist to sell works which allowed the artist to send money to his family even in his incarcerated state, was survived by his daughter, who even now tries to find the descendents of this prisoner so she can give them some of his artwork. On her living room wall is a portrait of her mother, done by the same artist and it is obvious from her interview that she, too, has respect for those her father used to guard. (NYCHS, 2007)

However, not all prisons have a culture that is conducive to positive staff involvement. In those, it is advisable to not have guards in the actual art room, since it may inhibit the inmates. (Hall, p 28) In some correctional institutions, officers may be so paranoid that they feel threatened by the images and either react with alarm or belittlement towards the inmates' creative expressions, further dehumanizing them. Even with paranoid reactions from prison staff, art therapy specifically can help inmates by its ability to allow an inmate to work out issues on a nonverbal level, beneath the radar of those who might otherwise be threatened by inmate expressions. However, this requires the art therapist to allow the staff to continue to see the art as benign and simplistic. (Gussak, p 60 & 61)

Based on the results of the positive staff interactions in several institutions, it seems possible that by carefully involving the prison staff in the display of a public exhibition of prisoner art, a highly strained and possibly abusive atmosphere could be affected in a beneficial way for both staff and inmates. It would have to be done in a manner which would not create resentment on either side and require a great deal of patience on the part of the person managing these events. Such an individual would do well to read Gussak's chapter "The Ultimate Hidden Weapon: Art therapy and the compromise option." in Drawing Time: Art Therapy in Prisons and Other Institutional Settings for advice on how to survive in the destructive dyadic relationship between staff and inmates that exists in some prisons. Changing the atmosphere of an institution does not happen overnight. It takes a lot of work and diplomacy.

A possible theme for an inmate art show that would be relatively benign, yet still beneficial to the inmate artists, the staff and the community, would be to have inmates create images of local historical interest. An elderly inmate at a Pennsylvanian correctional facility decided on his own to do such works, which were then put on display in a local mall. His works not only gave him a reason to research the history of the town, but gave other seniors outside of the prison something to talk about and engage their mental processes with. (Wisker, 1997, p 236) We talk about criminals paying their debt to society, what better way to do this than to educate people through their art, while grounding them in the very community most of them will eventually be released into?

This would, of course, be only the start of the art journey for an institution which has no positive art program history to draw from. It is hoped that eventually in these institutions, art could be done in a freer fashion, allowing both sides to benefit from it. As the Commission on Safety and Abuse in America’s Prisons states, "We must create safe and productive conditions of confinement not only because it is the right thing to do, but because it influences the safety, health, and prosperity of us all." (CSAAP, p 2)

Resources

The Commission on Safety and Abuse in America’s Prisons. (2006, June). Confronting Confinement. Retrieved April 21, 2007 from http://www.prisoncommission.org/pdfs/Confronting_Confinement.pdf

Dobnick, V. (2006, December 10). In prison, art supplies are likely to be coffee, candy. Associated Press. Retrieved April 18, 2007 from http://findarticles.com/p/articles/mi_qn4188/is_20061210/ai_n16902944

Gussak, David E. (1997). A Brief History. In D. E. Gussak & E. Virshup (Eds.), Drawing Time: Art Therapy in Prisons and Other Institutional Settings (pp. xv - xx). Chicago, Illinois: Magnolia Street Publishers.

Gussak, David E. (1997). Breaking Through Barriers: Advantages of art therapy in prison. In D. E. Gussak & E. Virshup (Eds.), Drawing Time: Art Therapy in Prisons and Other Institutional Settings (pp. 1 - 12). Chicago, Illinois: Magnolia Street Publishers.

Gussak, David E. (1997). The Ultimate Hidden Weapon: Art therapy and the compromise option. In D. E. Gussak & E. Virshup (Eds.), Drawing Time: Art Therapy in Prisons and Other Institutional Settings (pp. 59 - 74). Chicago, Illinois: Magnolia Street Publishers.

Hall, Nancy (1997). Creativity and Incarceration: The purpose of art in prison culture. In D. E. Gussak & E. Virshup (Eds.), Drawing Time: Art Therapy in Prisons and Other Institutional Settings (pp. 25 - 42). Chicago, Illinois: Magnolia Street Publishers.

Menees, Tim, (2001, September 30). If not art, then what? Pittsburgh Post Gazette. Retrieved April 7, 2007 from http://www.post-gazette.com/ae/20010930artprison0930fnp2.asp

Milligan, Nancy (1997). A Barbed Wire Garden: Art therapy in a maximum security prison for adolescents. In D. E. Gussak & E. Virshup (Eds.), Drawing Time: Art Therapy in Prisons and Other Institutional Settings (pp. 175 - 186). Chicago, Illinois: Magnolia Street Publishers.

NYCHS [New York Correctional History Society]. Fine Art Behind Bars. Retrieved April 19, 2007 from http://www.correctionhistory.org/html/chronicl/state/singsing/finearts/fineartsbehindbars.html

Ronaldson, Claudia (1997). The Lucky Ones: Probationary students in a special education school. In D. E. Gussak & E. Virshup (Eds.), Drawing Time: Art Therapy in Prisons and Other Institutional Settings (pp. 167 - 174). Chicago, Illinois: Magnolia Street Publishers.

Taylor, Marcia (1997). Growing Old the Hard Way: Art therapy as an intervention in gerontology and criminology. In D. E. Gussak & E. Virshup (Eds.), Drawing Time: Art Therapy in Prisons and Other Institutional Settings (pp. 197 - 209). Chicago, Illinois: Magnolia Street Publishers.

Wisker, Carol (1997). What One Museum Does for Prison Art. In D. E. Gussak & E. Virshup (Eds.), Drawing Time: Art Therapy in Prisons and Other Institutional Settings (pp. 231 - 239). Chicago, Illinois: Magnolia Street Publishers.

Woodall, J., Diamond, P. & Howe, A. H. (1997). Art Therapy in a Managed Care Environment. In D. E. Gussak & E. Virshup (Eds.), Drawing Time: Art Therapy in Prisons and Other Institutional Settings (pp. 99 - 126). Chicago, Illinois: Magnolia Street Publishers.

Ursprung, Will A. (1997). Insider Art: The creative ingenuity of of the incarcerated artist. In D. E. Gussak & E. Virshup (Eds.), Drawing Time: Art Therapy in Prisons and Other Institutional Settings (pp. 13 - 24). Chicago, Illinois: Magnolia Street Publishers.

Deconstructing and Interacting with Art

As with the exception to parenting I mentioned a few blog posts ago, I only partially agree with Dr. Pinker in his discussion of art and beauty. Classic beauty is probably a human constant and modern art does tend to reject it, but there is a purpose for the exploration of deconstruction and minimalization. The problem is, in my opinion, that many "progressive" artists stop at the deconstruction and never finish the journey to reconstruction. Therefore, making their own label an oxymoron because they never complete the process to allow true progress.

Golan Levin, on the other hand, does. As an engineer and artist, during the second half of his talk, he shows the progression from simplicity of gaze to one very engaging robot eye.



I see no problem with merging art and engineering. Di Vinci was an excellent example of an artist and engineer. Michelangelo and other artists were also scientists. So, again, we see the creative cycle of divergence and the convergence.

Going back to the first half of Levin's talk, he gives examples of mixing sensory inputs. Evan Grant also works on making sound visible, through the science of cymatics.



Sound does have form and affects matter. There is still much data hidden in nature for us to find.

Theories of Morality

I'm going to cheat on this TED talk and just give excepts from a class paper I did on moral development after the video.



. . . If finding out the early lives of Kohlberg and Gilligan is hard, finding information about someone as young as Jonathan Haidt is pretty much an exercise in futility. All that can be said for certain about his background is that he is a social psychologist who teaches at the University of Virginia and is currently a Research Fellow at the University of California Santa Barbara until the end of 2008. By all reports, he is an excellent teacher, who believes in positive psychology. (The Leigh Bureau, 2008) However, in an interview for Vox Day, a Christian libertarian opinion columnist (2007), Haidt states that he is an atheist, but one who believes that religion is an adaptation that generally works well in societies.

Well-versed in Kohlberg's and Gilligan's theories, Haidt notes that Kohlberg's cross-cultural research was focused on finding support for Kohlberg's own construct and did not address the local cultures' belief systems. Haidt and Craig Joseph desired to go beyond other moral theorists and search for the psychological systems that create moral codes. So instead of creating a moral theory based on the observation of a relatively homogeneous group of subjects and determining a cognitive development theory, they researched the moral codes and institutions of cultures across the world and through history to find constants. They also researched several moral theories, including Shweder's three ethics, which claims that Kohlberg's and Gilligan's theories only constituted one ethic--the ethic of autonomy--while ignoring the ethics of community and divinity. (Haidt, 2007) While Haidt's Moral Foundations Theory is not a developmental model, it does go beyond the Western Judeo-Christian value system, as well as the ethic of autonomy. The five psychological moral systems proposed by Haidt are listed on the Moral Foundations homepage as the following:

1) Harm/care, related to our long evolution as mammals with attachment systems and an ability to feel (and dislike) the pain of others. This foundation underlies virtues of kindness, gentleness, and nurturance.
2) Fairness/reciprocity, related to the evolutionary process of reciprocal altruism. This foundation generates ideas of justice, rights, and autonomy.
3) Ingroup/loyalty, related to our long history as tribal creatures able to form shifting coalitions. This foundation underlies virtues of patriotism and self-sacrifice for the group. It is active anytime people feel that it's "one for all, and all for one."
4) Authority/respect, shaped by our long primate history of hierarchical social interactions. This foundation underlies virtues of leadership and followership, including deference to legitimate authority and respect for traditions.
5) Purity/sanctity, shaped by the psychology of disgust and contamination. This foundation underlies religious notions of striving to live in an elevated, less carnal, more noble way. It underlies the widespread idea that the body is a temple which can be desecrated by immoral activities and contaminants (an idea not unique to religious traditions). (Haidt et al, 2008)

. . .

VI. Discussion

An observation made in the graduate level human development class, attended by the author of this paper, is the fact that hypothetical dilemmas cannot truly predict real life decisions. The lack of time, knowledge and resources may affect what someone might actually do in a situation. It was also pointed out that people will act at different moral stages depending on circumstances or priorities. Viktor Frankl's recollections from his imprisonment in Nazi concentration camps, in his book Man's Search for Meaning, is a perfect example of how people's moral can be changed by their circumstances. When people, due to external circumstances, physical illness or mental distress, are forced to a lower level of Maslow's hierarchies of needs, operating at a lower moral stage is to be expected. By linking morality to cognitive development, neither Kohlberg's and Gilligan's theories properly take into account this fluidity of moral decision making.

Based on Haidt's work, Kohlberg's and Gilligan's theories concentrate mostly on liberal values, setting some key conservative concerns at lower stages. Universities have long been considered bastions of liberalism, so this focus can hardly be a surprise. Unfortunately, as Haidt points out in his presentation at the 2008 TED conference, society cannot survive on liberalism alone. Both liberal and conservative forces are needed to keep a civilization viable. So to discount the conservative values in moral judgments is not only inaccurate, but creates unnecessary tension between different segments of society. While it is true that Haidt does not directly address the fluidity of moral decision making, his work does open the door by breaking down moral values into historic cross-cultural constants, instead using the moral preferences of the researchers. The main weak part of Haidt's research, based on the interviews done for this paper, is the belief that respondents will answer from their personal standards and not what they expect from others. Both Brett and the author of this paper share the belief that other people should not be held to their value system. The difference in their answers was based on the fact that while Brett answered as if judging other people, the author answered judging only herself. Haidt's questionnaire also doesn't take into account if someone considers resisting a particular value or two to be a high priority, as in the case of Elena, who is rebelling against the strict values of her adopted country and its religion-based government.


VI. Conclusion
Kohlberg's stages of morality, while still partially useful for most Westerners, is more accurate for liberal males than any other population. Even though Gilligan's theory mirrors Kohlberg's to some extent, it is difficult to use when there are no ethic of care considerations mentioned. Both theories lack real world moral predictive qualities, though they might give one an idea of a person's cognitive development. The idea that higher cognition leads to greater morality seems implausible when one considers that there are intelligent people with no morals at all, as well as very moral people with impaired cognition. Higher cognition may help make more effective moral choices, but it doesn't make a person more moral. That said, it is easy to see why someone who highly values education, like Kohlberg or Gilligan, would emphasize cognition. Indeed, it can be successfully argued that it is the duty of a moral person to check their facts and reasoning before making a decision. Such behavior falls under being prudent. Yet, as Haidt points out, a major percentage of people act like lawyers--making justifications for their actions after the fact, instead of considering the consequences before doing them. (Haidt, 2007)

Haidt's theory appears to be more predictive of behavior, since it focuses on types of values instead of a cognitive path or two of developing moral values. Possibly because of the biases of his predecessors, Haidt has been more vigilant in challenging his own biases and has worked to understand the "other side". It is not an easy thing to do, but the work of Haidt and of other theorists, such as Shweder, is a good start. Moral psychology and moral development theories still have a long ways to go before they can achieve the reliability of physical developmental models. Despite their shortcomings, however, these theories have provided frameworks on which moral thought can be discussed and studied.



Resources

Day, V. (2007). Interview with Jonathan Haidt. Retrieved on October 11, 2008 from http://voxday.blogspot.com/2007/11/interview-with-jonathan-haidt.html

Haidt, J. (2008). The real difference between liberals and conservatives. TED 2008 Conference. Retrieved September 16, 2008 from http://www.ted.com/index.php/talks/jonathan_haidt_on_the_moral_mind.html

Haidt, J., Ditto, P., Graham, J., Iyer, R., Joseph, C., Koleva, S., and Nosek, B. (2008). Moral Foundations Theory homepage. University of Virginia. Retrieved October 11, 2008 from http://faculty.virginia.edu/haidtlab/mft/index.php

Haidt, J., & Graham, J. (2007, March). When Morality Opposes Justice: Conservatives Have Moral Intuitions that Liberals may not Recognize. Social Justice Research, 20(1), 98-116. Retrieved September 28, 2008, doi:10.1007/s11211-007-0034-z

The Leigh Bureau (2008). Jonathan Haidt - bio. Retrieved October 11, 2006 from http://www.leighbureau.com/speaker.asp?id=410

Narcissistic Personality Disorder: Illness or Character Flaw?

I've seen a lot of posts on the Narcissist Personality Disorder on my Google Reader recently. However, I've notice that most of them are not going off of recent research. The information in this paper is two years old. It is not the final format, but all the material is here.

Narcissistic Personality Disorder: Illness or Character Flaw?

Written by Amanda D. Barncord Doerr

CHAPTER 1. INTRODUCTION

Initial shock

Walking out of a therapist's office after being told that their loved one is exhibiting the symptoms of a Narcissistic Personality Disorder (NPD), a person is forced to consider the implications of this diagnosis. There is confusion about how this diagnosis affects their view of their loved one, whether the NPD should be pitied or scorned. There is curiosity about the disorder itself and the affect, if any, it would have on the self view of the one diagnosed. And then there are worries about what the diagnosis means to the therapist treating the loved one and what is the prevailing thought on the Narcissistic Personality Disorder among mental health professionals.

Two views

In the literature available to the general public, there can be found two very diverse views of the Narcissistic Personality Disorder. The more accessible sources appear to portray the disorder as a character flaw or a label for difficult people. Popular author and psychiatrist, M. Scott Peck (1983) said in his book People of the Lie: The Hope for Healing Human Evil that evil people could appropriately be classified as a variant of the narcissistic personality disorder. On a website that approaches the disorder from a layperson's perspective, Joanna Ashmun (2004) points out that in the clinical literature NPD is usually discussed as a "character disorder".

On the other hand, the inclusion of Narcissistic Personality Disorder into the DSM, would strongly suggest to many people that it is an illness. Indeed many online "psychology" sites call it just that. Though to some laypeople it is more likely to suggest that the psychology field is trying to explain away a set of character flaws by suggesting that the "sufferer" is not responsible for their actions. Of course, the laypeople who cling to this notion of irresponsibility in the mental health field rarely believe in the need to view the sets of behavior that comprise an NPD in an objective and scientific manner.

Self-proclaimed NPD sufferer and author of Malignant Self Love : Narcissism Revisited, Sam Vaknin (1997) confuses the matter further with his views on whether or not narcissistic personality disorder sufferers can help themselves on his website. He first convinces the reader that a narcissist cannot help themselves and then goes on to show that the essential ingredients to remission is for the narcissist to be humble and take responsibility for his own actions.

Professional questions

All of this leads to the following questions. What is the professional view of the Narcissistic Personality Disorder? What data supports this view? Does treating NPD as a illness give any relief to the life impairment caused by it? What are the alternatives for narcissistic personality disorder sufferer and those who must interact with them?

CHAPTER 2. DIAGNOSIS

Background and history

Narcissism may be one of the most commonly recognised character flaws. The word itself comes from the Greek myth of Narcissus, a young man who fell in love with his own image in a pool and then was turned into a daffodil by the gods for punishment for his hubris. Ellis and Nacke first introduced the term into psychiatry at the end of the 1800s, but it took Freud and Rank in the 1910s to describe the disorder. Reich an Horney expanded on the concept some in the 1930s. Then for about 40 years the issue laid practically dormant until the 1970s, when Kohut and Kernberg connected the developmental processes of self to the formation of pathological narcissism. It was their work that introduced the Narcissistic Personality Disorder (NPD) into the DSM. (Rivas, 2001)

Symptomology

According to the research of Dimaggio, Semerari, Falcone, Nicolò, Carcione, & Procacci (2002, December), NPDs often display vague sensations of emptiness, boredom and emotional anesthesia. Their emotional state is not available to their consciousness. This cognitive deficit is a form of alexithymia. Alexithymia is the inability to link the physical response to words, fantasies, and feelings to the expression thereof. An example is when an NPD shows facial expressions of annoyance, but when asked about the annoyance, they will deny feeling anything and may even start looking confused when the questioner continues to probe the matter. This lack of self-awareness makes self-reflection very difficult for the NPD. To compensate, they rely on having a rigid set of values to help make decisions and judgments. However, unable to recognise the internal signals that guide most people when there is conflict between their beliefs and actions, NPDs will often act in counterproductive ways.

One side effect of the value system reliance is that NPDs usually display two main states of mind; admiration and contempt. The overt admiration state involves disdainful grandiosity, fantasies of wealth, power, physical attractiveness, and invulnerability. The covert contempt state involves an out-of-place sensitiveness, a sense of inferiority, insignificance and fragility, and a search for glory. It is usually during the therapeutic process that other states, such as anger, envy, fear and confusion are displayed.

The rigid value system also creates many interpersonal problems when compounded with other aspects of the disorder, such as a sense on entitlement and a haughty demeanor. Unable to reflect upon their own actions, NPDs also lack the ability to emphasize with others, seeing them instead as "self-objects". This deficit in object relations has been recognised in NPDs since the works of Kohut and Kernberg. When speaking to others, NPDs tend to be rhetorical, vague and evasive in their speech, with an egocentric view of reality. It has been noted that while NPDs transmit nonverbal signals, they do not receive them. And while they may not be able to reflect on their feelings, they can use them as an engine for social action.

Despite the NPD's belief that they should only associate with other special people, they are threatened by "kindred spirits" and will treat anyone who may be their equal as competition, instead of as a compatriot. The fragile self-esteem of the NPD does not allow for true peers. Nor does it allow for narcissistic damage in the form of insult or loss of esteem. Robert Simon (2002) noted that the actions caused by such damage resembled PTSD, without the flashbacks. This would include the outbursts of anger and other antisocial acts associated with narcissistic rage.

According to Phebe Cramer (1999), NPDs are more likely than other personality disorders to seduce their environment to meet their needs. When this fails, they will fall back on rationalization as a defense, resorting to fantasy and complete denial when that fails.

DSM criteria

For a patient to be diagnosed with having a narcissistic personality disorder, five of the following nine criteria must be met: a grandiose sense of self; a preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love; the belief that the patient is special and can only be understood by other special people; a need for excessive admiration; a strong sense of entitlement; a pattern of taking advantage of other people to met their own needs; a lack of empathy; a sense of envy towards others or the belief that others envy them; arrogant behavior. (APA, 2000)

Prevalence

According to the American Psychiatric Association (2000), the prevalence of NPD is less than 1% of the general population and 2 to 16% in the clinical population. In 1999, Rivas (2001) pointed out that the Narcissistic Personality Disorder was removed from the tenth revision of the International Statistical Classification of Diseases and Related Health Problems, leading some researchers to believe that maybe NPD was a cultural disorder, specifically an American one. However, studies supported by by the National Project of Mental Health of the Istituto Superiore di Sanità, Rome, Italy (Dimaggio et al, 2002), have since given a great deal of insight into this disorder.

CHAPTER 3. VALIDITY

Character disorder

It is not without good reason that researchers like Joanna Berg (1990) and others refer to NPD as a "character disorder". Some of the more noted aspects of this disorder is a high sensitivity to criticism, grandiosity, a sense of entitlement, a lack of empathy, envy and a need for excessive praise. All of these are considered character flaws in Western civilization. In fact, if we were to compare the traditional seven deadly sins with the criteria for NPD, we would be easily be able to match three - envy, pride and greed to the DSM-IV's list. Add narcissist rage to match with wrath, and we have over half the deadly sins. Compare the diagnostic criteria with any established religious code and one might begin to wonder why the NPD is seeing a therapist instead of a religious advisor. After all, Cramer (1999) said that the NPD does have a remnant of a moral conscience. Why is a deficiency of morals being addressed in in a manual for mental disorders in the first place?

The answer is quite simple. These people have behavioral problems that need to be treated and most of them do not have the ability to acknowledge their own faults. But still, it is interesting to note that Links & Stockwell (2002) found that some pathological narcissism can be cured through real life accomplishments. If able to achieve a major real life accomplishment, a NPD can be helped to reflect on their success. Once this reflection occurs, the NPD often ends up with a more realistic view of themselves and no longer needs to hold on to the fantasies of success, wealth and power they had been previously clinging to.

Another example of a successful treatment of NPD comes from Nicolò, Carcione, Semerari & Dimaggio (2007). It requires the therapist to time when they are caring towards the NPD to coincide when the NPD is willing to accept the idea that it is okay to be flawed. Then the therapist's help is seen as an enrichment, instead of an insinuation that the NPD is fatally flawed. In the case study given, the female NPD patient found acceptance for being helped through her own childhood memories of helping elderly strangers in a public restroom.

The two ways listed in this paper of affecting NPD in a positive way does reflect the adage that for a NPD to be cured, they must first learn humility. Then, as Sam Vaknin (1997) said, they must take responsibility for their actions. One cannot miss the fact that humility and responsibility are considered positive character traits in this culture, calling to mind the question again, should character flaws be grouped with mental disorders?

Cognitive deficits

But is NPD really a set of behaviors caused by a lack of moral fiber? Or the results of cognitive defects? The evidence of alexithymia, the inability to reflect on their own actions, not being able to receive conversational cues, and the disturbances in object relations all suggest that there is something going on inside the mind of the NPD that has nothing to do with moral turpitude. Stevens et al (1984) reported that NPDs felt a great deal of discomfort while experiencing considerable excitement. And what of Simon's finding that narcissistic damage resembled PTSD in many ways? Perhaps the problem isn't the character, but the cognition of the sufferer.

Kohut and Kernberg both believed that NPD was a product of developmental problems (Stevens et al, 1984). In Kohut's self-psychology theory, the NPD is created through a deficit of parental mirroring or parental rejection at the infancy stage. Unable to develop a bond with their primary caregiver, the NPD holds on to the idealization of their own ability to affect their environment, until they can develop a bond with the therapist, which allows them to learn the developmental skills denied them as children. In Kernberg's theory of pathological narcissism, the same lack of parental warmth causes the creation of a grandiose self, which is unable to care for anyone else. For years, these two theories were referenced almost exclusively in NPD studies.

A proposed integrated narcissism model set forth by Dimaggio et al (2002) has through research and study, outlined a complex set of cognitive processes and the means by which the disorder perpetuates itself. While Kohut and Kernberg's work are still at the model's foundation, the model focuses more on the immediate meta-cognitive defect of the NPD instead of the developmental processes that created it. Since therapists rarely deal with the NPD at the time of their developmental disruption, this model is probably far more useful in treating those in practice.

Traits versus contextual

Hummelen and Rokx (2007) discussed that one problem with personality disorders is that people display consistent personality traits on an inconsistent basis, depending on the context these traits occur in based on many variables. Therefore, it is possible that an individual could display non-pathological traits in the therapist's office, while displaying very pathological behaviors with neighbors who are not available for interviews. Likewise, an individual may display previously unknown pathological traits in an office due to abnormal fears and stress of meeting with a "shrink", much like a person whose blood pressure rises whenever he is examined by a physician.

Relying on the DSM

Hummelen and Rokx also criticized the syndromal approach of the DSM, with its highly ambiguous definitions based on often unobservable behaviors. Such definitions lead to generalizations and the expectation that certain behavior will always be present. There is almost no consideration of the context of the behavior. After all, a world class soccer player would legitimately be able to say he is the best in his field and be used to entitled treatment from others, but unless the person treating him followed the sport, they might doubt the patient's claims.

The DSM (APA, 2000) itself admits that the Cluster B personality disorders resemble each other. NPD can also resemble the obsessive-compulsive personality disorder, the schizotypal personality disorder, the paranoid personality disorder, and manic or hypomanic episodes. Using the DSM alone for identifying this disorder is an exercise in eliminating other possibilities.

Using the MMPI and MCMI

Chatham, Tibbals, & Harrington (1993) state in their study that NPDs only show a significant difference on the hypomanic scale using the MMPI. This means that MMPI could not differentiate between a NPD and a legitimately talented person experiencing a mild case of mania. The MCMI was even less clear, scoring the NPD high not only on the hypomanic scale, but also the histrionic, narcissistic, and antisocial scales too. Chatham et al concluded that more data was needed for diagnosing NPD than was provided by these tests.

Using the Rorschach Inkblot test

Surprisingly, one of the tests that has consistently been able to designate NPDs from other disorders has been the Rorschach Inkblot test. Harshly criticized in the 1990s, Ganellen (2001) and others have successfully defended the test, stating that it is just as accurate as the MMPI in overall use, as long as it was used for the purposes it was originally intended for - a diagnostic test based on perception alone, with little attention paid to the projections. Weiner (1996) gives four examples of successful applications for the Rorschach: differentiating personality variables; measuring developmental changes in children and adolescents; monitoring improvement during psychotherapy; and identifying experienced distress in war veterans with PTSD. There is also evidence in at least 48 studies that the Rorschach can detect cognitive complexity, reality testing, general psychological stress, disordered or psychotic thinking, and disturbances in object relations. Published longitudinal studies have shown that the Rorschach variables were steady over time.

The disturbances in object relations is of particular interest in regards to the NPD. Both Kohut and Kernberg were object relations theorists and their theories of pathological narcissism depended in disruptions in the development of self and object relations. In Kohut theory, NPDs had arrested development. In Kernberg's theory, they were created through a developmental aberration. (Stevens, Pfost & Skelley, 1984) Therefore, it stands to reason that the Rorschach test would be a better instrument to detect pathological narcissism. In studies done by Hilsenroth, Fowler, Padawer and Handler (1997), the four variables usually elevated in NPDs are reflection responses, personalized responses, idealized responses and the egocentric index. Of these four, two - reflection and idealized responses, were found to be empirically comparable to the DSM-IV diagnostic criteria.

In an earlier study by Hilsenroth, Hibbard, Nash & Handler (1993), borderline and narcissistic personality disorders showed several differences using the Rorschach. Ironically, borderline personality disorders (BPDs) tend to show higher grandiosity than NPDs, while NPDs were more egocentric. BPDs were also more aggressive and used more primitive emotional defense mechanisms than other PDs. This might explain the findings of Hummelen & Rokx (2007), where neuro-imaging scans show BPD patients to consistently have a smaller and hyper-reactive amygdala.

While the Rorschach can be defended as a diagnostic tool, it is still open to misuse in clinical settings. As Weiner (1996) pointed out, it was never meant to be used for everything, nor was it meant to be used by those not thoroughly trained in evaluating it. One hopes that now the ability to diagnose NPDs through object relations has been proven that a less subjective test can be devised for it.

CHAPTER 4. CONCLUSION

Based on studies using the Rorschach test, other psychometric instruments and documented case studies, the current prevailing professional view of the narcissistic personality disorder would be that it a deficit of meta-cognition, probably caused by a disruption of self-development in infancy. While it is not treated with medication, approaching NPD as a disorder is very important because it easier to be less emotionally hurt by the sufferer's actions. This emotional distance is necessary when dealing with NPDs, since it allows one some control over how they are seen by the NPD. To get anywhere with an NPD requires the individual to be seen as admirable.

Cognitive therapy is the only course so far that has shown any success in treating NPDs. Confronting a NPD and calling them to repentance is pointless in most cases. The narcissistic defence system is far too sophisticated to be dismantled by such tactics. At best, the NPD will retreat into a depressive state and cycle through emptiness and fear until they latch onto their grandiose self and return to their pathology when the immediate threat of shame is past. A more successful approach is to guide the NPD to a point of real achievement, in either the present or the past, and help them to realize that not being powerful all the time is nothing to be ashamed of.

It is very easy to see how a lay person would question the diagnosis of NPD as a mental disorder, based on the literature and websites available to them. Upon seeing the criteria for NPD, many would understandably declare its sufferers as difficult people who should just straighten up their acts. However, as we look closer at the studies of NPD, it becomes apparent that the narcissist is suffering from a cognitive defect, which uses a rigid value system as a coping mechanism. Because of this coping mechanism, NPDs will have character flaws, but the treatment of the disorder is not in the flaws, but in the cognitive deficits. In his confusing way, Sam Vaknin is correct about his disorder. It is something that the NPD suffer cannot completely control, however, through humility and responsibility they can overcome their cognitive deficits. In a way, it is not much different than a bipolar patient who must manage their symptoms. The jury is still out as to whether NPD can be completely cured. It is tricky enough just to get the patient into the therapist office in the first place.

REFERENCES

American Psychiatric Association. (2000) Diagnostic and statistical manual of mental disorders, (4th ed.), Text revision. Washington D.C.

Ashmun, J. M. (2004). Narcissistic Personality Disorder (NPD) : DSM-IV Diagnostic Criteria. Retrieved September 02, 2007, from http://www.halcyon.com/jmashmun/npd/dsm-iv.html#npd

Berg, J. (1990, December). Differentiating ego functions of borderline and narcissistic personalities. Journal of Personality Assessment, 55(3), 537-548. Retrieved September 5, 2007, from PsycINFO database.

Chatham, P., Tibbals, C., & Harrington, M. (1993, April). The MMPI and the MCMI in the evaluation of narcissism in a clinical sample. Journal of Personality Assessment, 60(2), 239-251. Retrieved September 5, 2007, from PsycINFO database.

Cramer, P. (1999, June). Personality, personality disorders, and defense mechanisms. Journal of Personality, 67(3), 535-554. Retrieved September 5, 2007, from PsycINFO database.

Dimaggio, G., Semerari, A., Falcone, M., Nicolò, G., Carcione, A., & Procacci, M. (2002, December). Metacognition, states of mind, cognitive biases, and interpersonal cycles: Proposal for an integrated narcissism model. Journal of Psychotherapy Integration, 12(4), 421-451. Retrieved September 5, 2007, from PsycARTICLES database.

Ganellen, R. (2001, August). Weighing Evidence for the Rorschach's Validity: A Response to Wood et al. (1999). Journal of Personality Assessment, 77(1), 1-15. Retrieved September 22, 2007, from Academic Search Premier database.

Hilsenroth, M., Fowler, J., Padawer, J., & Handler, L. (1997, June). Narcissism in the Rorschach revisited: Some reflections on empirical data. Psychological Assessment, 9(2), 113-121. Retrieved September 5, 2007, from PsycARTICLES database.

Hilsenroth, M., Hibbard, S., Nash, M., & Handler, L. (1993, April). A Rorschach study of narcissism, defense, and aggression in borderline, narcissistic, and Cluster C personality disorders. Journal of Personality Assessment, 60(2), 346-361. Retrieved September 5, 2007, from PsycINFO database.

Hummelen, J., & Rokx, T. (2007, December). Individual-context interaction as a guide in the treatment of personality disorders. Bulletin of the Menninger Clinic, 71(1), 42-55. Retrieved September 9, 2007, from PsycINFO database.

Illness. (n.d.). The American Heritage® Dictionary of the English Language, Fourth Edition. Retrieved September 02, 2007, from Answers.com Web site: http://www.answers.com/topic/illness

Links, P., & Stockwell, M. (2002). The role of couple therapy in the treatment of narcissistic personality disorder. American Journal of Psychotherapy, 56 (4), 522-538. Retrieved September 5, 2007, from PsycINFO database.

Nicolò, G., Carcione, A., Semerari, A., & Dimaggio, G. (2007, February). Reaching the covert, fragile side of patients: The case of narcissistic personality disorder. Journal of Clinical Psychology, 63(2), 141-152. Retrieved September 5, 2007, from Academic Search Premier database.

Peck, M. S. (1983). People of the lie: the hope for healing human evil. New York: Simon & Schuster.

Rivas, L. (2001, January). Controversial issues in the diagnosis of narcissistic personality disorder: A review of the literature. Journal of Mental Health Counseling, 23(1), 22-35. Retrieved September 5, 2007, from PsycINFO database.

Simon, R. (2002, January). Distinguishing trauma-associated narcissistic symptoms from posttraumatic stress disorder: A diagnostic challenge. Harvard Review of Psychiatry, 10(1), 28-36. Retrieved September 5, 2007, from PsycINFO database.

Stevens, M., Pfost, K., & Skelly, R. (1984, March). Understanding and counseling narcissistic clients. Personnel & Guidance Journal, 62(7), 383-387. Retrieved September 5, 2007, from PsycINFO database.

Vaknin, S. (1997). Can the narcissist help himself? Retrieved on September 02, 2007, from http://samvak.tripod.com/narcissismselfhelp.html

Weiner, I. (1996, June). Some observations on the validity of the Rorschach Inkblot Method. Psychological Assessment, 8(2), 206-213. Retrieved September 22, 2007, from PsycARTICLES database.

white paper - successful interventions

White Paper - Addictions

Amanda Doerr

KEYS TO A SUCCESSFUL INTERVENTION

When many lay people talk about having an intervention with someone about their behavior, they tend to bring up scenes of verbally abusive behavior that is expressly prohibited by the ethical guidelines of the APA. Obviously there must be something wrong with this idea of ambushing a person with their bad behavior and beating them over the head with their flaws. Such behavior sounds more destructive than therapeutic. And indeed, described that way it is, this model of intervention sounds far more satisfying to the participants than useful to the recipient.

But then why do we have interventions and confrontations still in use? The answer is that professional interventions have developed a great deal since the Synanon program and its "attack therapy" as developed by Chuck Dederich in 1958 (Polcin, 2003). At that time, it was believed that the release of emotional energy would release tension and break down denial, thereby allowing a more honest discussion about the addiction and the behavior that resulted from it. The goal at the end was to reaffirm the confronted person's importance to the group. However, many criticized this technique as a replication of the abuse many of these clients experienced in their past. The same criticism could be applied to the early therapeutic communities that use humiliation and punishment to change the addict's behavior. Faced with the alienation by the respected mental health professionals, some therapeutic communities began to use group feedback methods in the 1970s and 1980s. This moved the focus from "breaking down the denial" to confronting the dysfunctional behaviors caused by the addiction. Other factors that brought about this transformation in methodology were: the increasing number of dual-diagnoses of addiction and mental illness, the desire to be allied with 12-step programs, and the research showing that addictions were fueled by core emotional issues.

While there are still disagreements as to what one means by "confrontation", some researchers and program directors prefer to define it, more or less, as "someone being approached, in a realistic but not punitive way, that 'bad things' might happen if they don't make changes in regards to their addiction" (Polcin et al, 2006). Personal attacks are discouraged, as well as other forms of disruptive confrontation. Perhaps the term "therapeutic confrontation" should be used more often to distinguished from the more hostile versions of confrontation, such as the "beat them into submission" type.

Studies show that successful interventions usually generate gratitude and good feelings towards the confronters by the confronted (Polcin, 2006). Given the all too human reaction to be offended when someone tells us we're wrong, how is this created in a confrontation?

One element is the relationship of confronters to the client. The closer the relationship, the more successful the confrontation because the information given is seen as more valid (Malis & Roloff, 2007). Among not so close peers, a great deal of face work has to be done to create enough of a valid bond for their views to be considered. In fact, that bond often has to be there before a peer will even consider confronting someone with their addiction. With therapists, this would be the creation of a therapeutic alliance. While some practitioners claim that this is not necessary, research shows that is does help and never hurts. A study by Miller, Brown, Simpson, Handmaker, Bien, Luckie, Montgomery, Hester, and Tonigan found that there was a strong positive correlation between supportive and empathic approaches and positive outcomes (Polcin, 2003).

To up the odds of an effective confrontation, many current professional intervention programs first educate those of the confrontation team how to phrase their concerns in "a realistic but not punitive way". Alanon facilitation and Johnson Institute interventions are ways that this is done (Polcin, 2003). While the Johnson Invention has high relapse rates, it has a higher rate of getting clients into treatment and still retains clients (Loneck et al, 1996). A more effective training program for the family and friends of a client is the Community Reinforcement and Family Training (CRAFT) program, which teaches behavioral change skills. According to Bob Poznanovich, CEO of Addiction Intervention Resources, they go even further and assess the situation of the family (Conan, 2008). In fact, Poznanovich claims that they work more with the family than with the addict, because family can often enable addictive behavior without realizing it. He calls it a "family illness" and points out that many people are given bad advice about how to deal with addiction, such as it is just a matter of will power or that there is nothing that can be done.

Another important element is the timing of the confrontation (Polcin, 2003). Light to moderate drinkers gain less from interventions than problem drinkers, probably because the concerns seem less valid. However, light to moderate drinkers do respond favorably to the more empathic therapies. Addicts with major cognitive impairment from the drug they're taking, respond better after a period of detox. Addicts already in being treated in a facility benefit more from a therapeutic confrontation after they have been there long enough to emotionally stabilize. Otherwise, they will flee or regress in response to the confrontation. In many programs, the client is educated about the positive role confrontation can play in their recovery. This preparation not only makes the confrontation less traumatic, but also puts the client in a mindset prepared to make the most of the information given to them during the confrontation.

It should be noted that some addicts, because of comorbid conditions, may not be good candidates for intervention. One cannot expect a paranoid or antisocial personality disorder to respond favorably to confrontations. Nor can one expect someone with diminished cognition to fully comprehend what they are being confronted with.

The most important element is the focus of the confrontation. According to a study by Polcin, Galloway, and Greenfield (2006), when the message was on the behaviors and potential problems, clients consistently said that they were more likely to have a positive experience with confrontations. Remarkably, the more frequent the confrontations, the more individuals involved, and the more sources involved, the more positive was the views of the confrontations. Thinking distortions can also be addressed as part of the confrontation.

An element of choice also makes an intervention more successful (Conan, 2008). When the addict is allowed the choice of whether to get better or suffer from their own behavior, and then chooses to get better, they are more committed to the change. Even if the addict chooses not to change at first, some will change their minds later as the "bad things" they had been warned about happen to them.

A skilled counselor should be directing the therapeutic confrontation, in case emotions run too high or a deep issue is triggered (Polcin, 2003). The counselor should be able to switch from a confrontive stance to a clinical exploration of the issues exposed. A far cry from the "beat them until they see the errors of their ways." Modern interventions are more about support for reducing dysfunctional behaviors, than they are about making the recipient admit that they are an addict.

In summary, a successful intervention requires: a trusting and supportive relationship between the client and the intervening group; focusing on the dysfunctional behaviors and possible bad outcomes from the addiction; the client and interveners to be prepared to make the most of the situation; and a facilitator to handle any problems. Education for the family, friends, and client increases the chances that the intervention will be more effective as does the number of confronters and interventions. While old fashion interventions might make for great television drama, forcing the client to admit that they are an addict or otherwise personally attacking them, is more likely to impede than to help the situation.

Resources

Conan, N. (2008). Addicted Loved Ones: When to Intervene?. Talk of the Nation (NPR), Retrieved April 17, 2009, from Newspaper Source database.

Loneck B; Garrett JA; et al (1996). The Johnson Intervention and relapse during outpatient treatment. American Journal of Drug and Alcohol Abuse, 22(3):363-375. Retrieved April 17, 2009, from Academic Search Premier database.

Malis, R., & Roloff, M. (2007, January). The effect of legitimacy and intimacy on peer interventions into alcohol abuse. Western Journal of Communication, 71(1), 49-68. Retrieved April 17, 2009, doi:10.1080/10570310701199186

Polcin, D. (2003, January 15). Rethinking Confrontation in Alcohol and Drug Treatment: Consideration of the Clinical Context. Substance Use & Misuse, 38(2), 165. Retrieved April 20, 2009, from Academic Search Premier database.

Polcin, D., Galloway, G., & Greenfield, T. (2006, February). Measuring Confrontation During Recovery From Addiction. Substance Use & Misuse, 41(3), 369-392. Retrieved April 20, 2009, doi:10.1080/10826080500409118