April 12, 2009
Regular readers of Philip Dawdy’s excellent Furious Seasons web site will be familiar with his opinion of the DSM’s bipolar II diagnosis. In keeping with his idea of “a free market of ideas in the mental health world” I would like to contribute my opinions on this topic.
First, let me be clear: I admire Phillip’s work on Furious Seasons, have supported his fundraisers, and hope he keeps at it.
The opinion that causes some controversy is succinctly put in his interview with Christopher Lane in Psychology Today.
Here’s the quote in full:
I may be the only writer in America who thinks BP2 is controversial and I can hardly think of any doctors who do. For me, it’s a questionable classification and something of a cop-out by the DSM writers for a couple of reasons: One, BP2 isn’t bipolar disorder, properly understood. There’s no mania, there’s no hospitalization for mania, and there’s no one running naked down the street. The most prominent features of BP2 are depression (and that covers the vast majority of a person’s time who is diagnosed with BP2) and bursts of energy, broadly understood. To me, that sounds a whole lot more like depression and agitation than it does manic-depression.
Two, the minute someone gets hit with a bipolar disorder diagnosis of any subtype, then they are faced with a profoundly bad set of social assumptions; they get stigmatized by friends and family; and they lose their jobs. I know of multiple cases along these lines, including one of a sheriff’s deputy in King County, Washington who was fired from her job as soon as the brass learned she had BP2, even though she had a stellar track record as a cop and had done nothing wrong on the job. That hardly seems fair when we’re talking about a disorder that doesn’t involve hallucinations or psychosis and has none of the off-the-charts impulsivity of true manic-depression. While it’s nice of researchers and mental-health advocates to claim that we’ve got to end this kind of stigma, in the real world that would take generations and by then people with BP2 today will have reached the ends of their natural lives.
Why BP2 wasn’t called something else is beyond me, but the diagnosis has sure caused a lot of unfair social damage.
I have a BP2 diagnosis, the comical history of which you can read here, and Phillip’s description in the first paragraph doesn’t characterize my experience at all well. The reason I have a BP2 dx rather than BP is that I haven’t suffered “marked functional impairment” in any of my “hypomanic episodes”. If I had then DSM 4’s criteria would have me as BP.
Hospitalization is not a required criterion for diagnosis of mania or BP. Nor is running naked down the street. What I experienced included delusions (e.g. I once began planning to become Prime Minister), paranoia, demented spending (thankfully I had no lines of credit when the behavior was worst when I was younger or it would have been ruinous), crazy creativity with loss of my self-critical faculty, no sleep, ludicrous self-esteem and embarrassing incidents the memory of which make me wince decades hence. This is a bit more than a “burst of energy, broadly understood”. And there is suspicion of genetic evidence: my father’s odd behavior and suicide smacks of manic depression. I rather agree with my shrink that the criteria of mania and BP are met rather closely except that, because I never lost a job, got kicked out of school, got arrested or was hospitalized, it lacks “marked functional impairment”. In other words, I got away with it. Apparently that makes it BP2.
Nor is this behavior agitated depression. I have a lot of experience with that and it is entirely different. In agitated depression my mood is dysphoric, pessimistic and cynical but I can’t sleep, relax or let up with the negativity whereas in hypomania I am euphoric, self-confident, optimistic and at one with the world. There’s no way to confuse these states, in my experience.
On Philip’s second point, I don’t really disagree but the statement sounds a little sweeping. I’m sure some people have suffered negative and unfair social consequences but I’m not aware of any affecting me, at least not so far and certainly not within the first minute of diagnosis.
Whether or not a different name for this disorder would, on the whole, have been better for patients, I really don’t know. Would the social consequences for something called, say, Major Depression with Hypomania (with, as most new psychiatric disorders have, a three letter abbreviation, say MDH) be any better? I don’t find that very convincing but I honestly don’t know.
Moreover, I imagine there may be benefit to patients from the BP2 name. It seems clear from the reading I’ve done that it’s important to treat BP2 in basically the same way as bipolar, especially in regard to the dangers of antidepressants. I imagine that many (most?) physicians are aware of these concerns in bipolar. My own GP refused to prescribe an antidepressant because of his suspicion of bipolar. He sent me to a psychiatrist who refused to prescribe an antidepressant without first a robust mood stabilizer. It took two years to get that right before I was given the antidepressant. According to, for example, Husseini Manji, this is the safest approach. (He even prefers in cases of MDD that are familial.)
If BP2 had instead a name that failed to make the association with bipolar, I wonder if some physicians, especially those who aren’t psychiatrists, might be less likely to recognize these risks. Given that most BP2 patients present with depression, the association with the bipolar word may spare them some risk.
June 12, 2008
A recent conversation with my friend Ken touched on the astonishing drama that fills the lives of many of the students at the community college at which he works and how starkly this contrasts the lives of his own milieu. I described my view of the opposite regime: the middle-class suburb where the safe standardized environments of home, school, church and neighborhood enforce strict bounds on thought and behavior and indoctrinate their own narrow values and aspirations to produce a homogenized, neutered humanity. Later the same day I happened to read the following passage in Thomas Bernhard’s memoir that addresses the same issue but in Bernhard’s dazzling prose.
Background to the excerpt: Thomas Bernhard, was a sensitive child and had a mostly very unhappy childhood which spanned WW2. His family was impoverished but essentially middle-class in values, behavior and ambition. Shortly after the war, living in Salzburg, Bernhard was attending grammar school, which he hated, when one day while walking to school he took the opposite turn on the Reichenhaller Strasse from the direction to the school and instead visited a labor exchange where he got a position as apprentice at a grocery store in the blighted Scherzhauserfeld Project.
The excerpt is from Gathering Evidence by Thomas Bernhard, chapter 3: “The Cellar: an Escape” pp192-194 in the David McLintock translation published by Vintage in 2003.
What I was seeking was something different, something I had not known before, something that might be stimulating and exciting, and I found it in the Scherzhauserfeld Project. I did not go there out of any feeling of pity: I have always detested pity, and especially self-pity. I did nor permit myself to feel pity; my only motive was the will to survive. Having come so close co putting an end to my life, for every possible reason, I had the idea of breaking away from the path I had taken for many years because I was too stupid and too unimaginative to choose another, and because I had been set upon this path by those who brought me up to fulfill the dreary ambitions they entertained on my behalf. I did an about-turn and ran back along the Reichenhaller Strasse. At first I simply ran back, without knowing where I was heading. From this moment on it’s got to be something different, I thought—in my excitement this was the only thought in my head—something that is the very opposite of what I have done up to now. And the labour exchange in the Gaswerkgasse was exactly in the opposite direction. Under no circumstances would I have turned again and gone in any other direction. The farthest point in the opposite direction was the Scherzhauserfeld Project, and it was on this farthest point that I set my sights. The Scherzhauserfeld Project was the farthest point in every respect, not just geographically. There was nothing there to remind me even remotely of the city and of everything in the city that had tormented me for years and driven me to despair, to thinking of scarcely anything but suicide. Here there was no mathematics master, no Latin master, no Greek master, and no despotic headmaster to make me catch my breath whenever he appeared. Here there was no deadly institution. Here one did not continually have to keep oneself under control, keep one‘s head down, dissimulate and lie in order to survive. Here I was not constantly exposed to the disapproving looks I had found so deadly. Here no outrageous and inhuman demands were made on me. Here I was not turned into learning and thinking machine. Here I could be myself. And all the others could be themselves. Here people were not constantly being pressed into an artificial mould as they were in the city, in a manner that daily grew more sophisticated. They were left in peace, and from the very first moment I set foot on the Scherzhauserfeld Project I too was left in peace. One could not only think one’s own thoughts: and one could express them, when and how one liked and as loudly as one liked. One was not in constant danger of being attacked for being headstrong. One‘s personality was suddenly no longer suppressed and crushed by the rules of the bourgeois social apparatus, an apparatus designed to destroy human beings. In towns where stupidity reaches such alarming proportions as it does in Salzburg, human beings are constantly tweaked and shaken, constantly hammered and filed into shape, and they go on being hammered and filed into shape until there is nothing left of the original human being but a revolting, tasteless artifact. In towns of medium size (I will say nothing of small towns, where everything is grotesque) every effort is directed toward turning human beings into artifacts. Everything in these towns is opposed to human nature; even the young are nothing more than artifacts from A to Z. The human species today can preserve itself only in the unadulterated country or in the unadulterated big city—only in the unadulterated country, which still exists, or in the unadulterated big city, which also exists. In such conditions one still finds natural human beings—beyond the Hausruck or in London, for instance, and as far as Europe is concerned one probably finds them nowhere else. For in Europe today London is the only genuine big city; admittedly it is nor on the continent, but it is in Europe all the same; and beyond the Hausruck I can still find the unadulterated country. Everywhere else in Europe one finds only artificial human beings, people whom the schools have turned into artifacts. Whoever we meet in the rest of Europe turns out to be an artificial human being, a tasteless replica of the real thing. The number of such products runs into millions and—who knows?—will perhaps shortly run into billions; and all their movements are controlled by various educational systems, which are in reality pitiless, insatiable, man-eating monsters. All the time our ears are assailed, if we are still capable of using them, by the sickening din of mass-produced marionettes with not a single natural human being among them. It is possible that in the Scherzhauserfeld Project I experienced the Hausruck or London effect, but I was not conscious of this at the time. I had obeyed my instinct and gone in the opposite direction.
June 4, 2008
The magical power of LEDs induces in the hearts and minds of engineers and the technically minded an unequivocal knowledge: The product needs to have LEDs. The understanding of this truth arises at a deep, almost emotional level in ones being and develops into, at the cognitive level, an unshakable axiom. Few will notice that they have become gripped by a mystical alien force but all have experienced it.
The pressure of this knowledge that the LEDs are needed is all but irresistible. A weaker engineer will simply add LEDs without much thought. But in a stronger, more disciplined engineer it can lead to difficulties brought about by a cognitive dissonance between the magical knowledge on the on hand and, on the other, the widely held belief that a product’s features ought to bear up to rational justification.
The uses of LEDs that we see in the products that surround us are all examples of the various resolutions of this cognitive dissonance. Occasionally an actually useful function can be found – a rare and happy outcome. Sometimes the designer seems to have accepted ornamentation as sufficient excuse. But the more common outcome is a contrivance of utility. On the one hand it can be a plainly pathetic apology for function, as exemplified by the entire category of “debugging by LEDs” applications (see diagram). At the other extreme it can be a truly brilliant contrivance that succeeds in creating the illusion of a purpose; an outcome that reflects an uncommon creative talent of the designer. Nevertheless it remains a contrivance – a fig leaf concealing an ineffable.
In organizations the cognitive dissonance can become collective. The scenario is not unfamiliar: certain stakeholders advocating utility, others hiding behind tradition (i.e. standards) but none challenging the authority of the magical truth that the LEDs are needed. The time spent searching for a compromise acceptable to all can run into years.
And who has not experienced the classic cop-out of a hardware designer who, unable to find a plausible pretext on his own, passes the buck by placing the LEDs under software control? It is in this situation that it has been know to happen that a lowly programmer might inadvertently utter the taboo question “What are these LEDs supposed to be for?”
You may wonder but you may not ask.
June 3, 2008
In office life, people do strange and mysterious things — things clearly not directed towards the goals of the organization. Examples:
- convening completely unnecessary meetings
- counter-productive business development projects, mergers and acquisitions
- long carefully written emails when a short phone call would work better
- micro-management of perfectly competent workers
The Worster Principle can help us understand such strangeness and mystery. It is provides a straightforward explanation that can be stated thus:
When an obstacle prevents somebody from doing what he or she ought, the person will do something else instead – and the person will normally do something that he or she knows how to do and that looks approximately like work.
So the Worster Principle separates real-work, what the person ought to be doing, from not-work, the strange actual behavior that approximately imitates work. It also isolates the obstacle that impedes the real-work.
Thus the three key elements to look for when applying the Worster Principle are:
- real-work – what the person ought to be doing
- obstacle – what prevents the person for doing real-work
- not-work – what the person is actually doing instead
The principle can apply regardless of what each of these are and only requires a little bit of strangeness and mystery in order to work correctly. In particular, it works regardless of the obstacle. Incompetence, laziness, organizational blocks, lack of motive, lack of needed tools or resources, or almost anything else can all be valid obstacles in a case of the Worster Principle.
Further, the principle says nothing about the connection between real-work and not-work. In fact, there is usually no direct link. The specific not-work is determined much more by factors intrinsic to the person and by his or her circumstances than it is by the specific real-work that isn’t being done.
Let’s practice using the Worster Principle in a few example cases.
The first example is the easiest: the endemic problem of micro-management. Competence in management is rare and managers often don’t have the skills needed to manage sensibly. So incompetence can be an obstacle that prevents some managers from doing their real-work. And many of those will choose micro-management as their not-work. It’s easy to do, it has the approximate appearance of work, and corporations typically supply role-model micro-managers for newbies to learn from.
In the next example the obstacle is more mysterious. Most people in corporate life experience unnecessary meetings or unnecessarily protracted meetings without resolution. Since these are clearly examples of not-work—activities that look approximately like work but are in fact not what anybody ought to do—the Worster Principle may apply. If so, you can sometimes be lucky enough to identify the obstacle. In practice, it can be very diverse. Boredom with real-work is not uncommon. Personal insecurity is another possibility: a manager might organize meetings aimed at the diffusion of responsibility for decisions that he or she ought to accept individually.
Another endemic problem in business is inappropriate mergers and acquisitions. Studies from reputable authorities consistently show that the vast majority (probably around 80%) of M&As lead to net destruction of business value. So very likely most of them are not-work. The reasons why this particular kind of not-work is so popularly chosen over the others are probably not hard to guess (try machismo, braggadocchio, add your own Latinate words). But more interesting, assuming we’ve decided that the Worster Principle probably applies, is figuring out the real-work and the obstacle. More often than not, the real-work is the old-fashioned way of making your business more valuable, e.g. expanding sales, increasing operational efficiency, reducing costs due to quality problems, keeping customers happy, etc., blah, blah, yawn,… all that tired old advice filling so many sleepy-making business manuals. But why are these important things not being done? First it’s because they are difficult, require considerable insight and honesty, involve a lot of hard work that’s not much fun and they attract very little attention to an ambitious executive. Moreover, if one succeeds at the real-work, one is normally punished by budget reductions reflecting the cost savings achieved and/or setting of bold “stretch goals” for next year based the metrics of the recently achieved successes.
Try applying the Worster Principal yourself when things in the office seem more silly than need be. It’s very simple at one level, but it really does help one understand real world situations. We sometimes tend to focus on the manifest problem, i.e. the not-work, and the Worster Principal helps redirect our attention back to what should be happening and why it isn’t. When the obstacle to real-work can be identified, you may find a practical way to remove it.
Mr. Worster has been enjoying office life since 1987. Surprised that the principle described above appears not to be a standard chapter in the mighty cannon of management studies, he gave it his own name hoping that, once publicized, acknowledged for its truth, acclaimed for its breadth and depth of utility, and installed in every respectable MBA curriculum, it will afford him a measure of immortality.
May 28, 2008
Riding in the burbs, boonies and exurbs in orbit around Boston, as I often do, there is ample opportunity to contemplate the nature of human behavior. In those situations I am often interested in the behavior of people driving cars. I observe, record, tally, analyze, and classify. Recognizable patterns arise. Sometimes with sufficient definition to have some predictive power. And sometimes I like to wager a hypothesis as to the cause of the patterns.
Within the broad class of drivers who’s aim appears to be to maintain strict limits on the distance between their car and the one ahead of them on the road, some are more urgent in their efforts than others. Of course, the only thing that can be achieved (on the roads I cycle on) by accelerating a car is reduction of the distance to the car ahead. But most drivers avoid colliding with that car and few will ever pass it so they just end up maintaining a certain distance. This then appears to be the goal, maintaining strict upper and lower bounds on that distance.
Thus these drivers appear to be motivated to either a) get close to a car, if they aren’t already, or b) to stay close it if they are. I’d say that the majority of motorists in Eastern Mass. display this behavior.
Nothing new there, of course, but what’s interesting is the priority of this goal relative to other dimensions of the driving experience. Some will risk the safety of a cyclist in pursuit of this goal. This is actually quite common. By no means the majority of drivers do it but for cyclists it’s a routine experience.
Before postulating the underlying reasons for such behavior, let’s estblish some simple facts:
- The opportunity to pass a cyclist safely when it isn’t now is usually only a matter of seconds away.
- The consequences for the driver, his or her passengers or anyone else in the world of waiting those seconds are almost certainly nil. Even if the wait is 30 seconds (extraordinarily long), it’s only going to be a minute or two before the car in front has been regained, so arrival time for the journey will not be affected. Even if it were, what do 30 seconds matter?
- The consequences of passing a cyclist unsafely can be very serious. While the life of the cyclist may be of some concern to the driver, almost all would prefer to avoid a collision with an oncoming vehicle. Even on slow country roads the relative speed of the vehicles can easily reach 60 mph — enough cause injury (even with today’s safety technology) and cause considerable inconvenience.
So there is no incremental cost to anyone if the car passes safely as opposed to unsafely. But there is potentially high cost to driver, passengers, cyclist, other road users, emergency services, families, etc. to passing unsafely. The choice to pass unsafely is therefore irrational.
And that’s what makes it interesting. Why do people make that choice?
- They don’t know that their driving is unsafe?
- They feel that they are safe and don’t care about the cyclist or other drivers?
- They feel entitled to drive without having to slow down to the speed of the vehicle in front if that vehicle is a bicycle?
I’m sure you can think of more possibilities. But in any of these three cases, the position taken is clearly unsupportable by obvious and available facts. So there’s a fair chance that a cognitive dissonance is involved.
My guess is that the core underlying cognition is a belief that one is important and that one’s journey is urgent. It’s obvious that neither is true, hence dissonance. So cognitions consonant with the core cognition of self importance are piled on: “I shouldn’t have to wait for cyclists.” “Cyclists should be on the shoulder or sidewalk.” “This is a 40 mph road.” and other such nonsense. (I’ve heard all of those from drivers, btw.)
One that I heard earlier this year really stuck with me. I was riding on a Sunday morning in the pastoral burbs arourd Acton or Westord or somewhere like that with a group of three other cyclists. The stretch of road was straight, narrow enough so a car had to cross the center line to pass, but undulating enough that you couldn’t always see what was coming the other way. We were riding in line carefully at the right, knowing that traffic wanted to pass. One car began a passing maneuver without being able to see beyond an oncoming rise in the road. It got half past us when an oncoming car emerged over the now very near crest of the rise. The passing car slowed and moved right forcing two of us to brake to make space. The oncoming car had to stop.
One of our group had a word with the driver. She declared in her defense: “But we live here!”
For a cognition to reinforce the core self-importance cognition, that’s reaching pretty far into the absurd. “But we live here!” She was perfectly serious. She was driving a Subaru.
I mention the brand of car because I’ve noticed that among the minority of drivers who choose to pass unsafely rather than safely, Subaru (Scooby-Doo as call it) and mini-vans are over represented. And I’m curious as to why.
And so finally to my outlandish conjecture. If I were living in a vinyl-sidewall house on a standard plot in a banal subdivision of a town without one decent restaurant, without a bar women can comfortably frequent, without a cinema, a theater, art gallery, with virtually no cultural or intellectual life but with plenty of churches, and I had to face that fact that I had sacrificed my foreseeable future to little more than the transportation of groceries and thankless children, I’d be pretty pissed off too. It would be hard to resolve that dissonance by adding consonant cognition. What alternative would I have? So I’d be living in constant tension and insecurity regarding my self-importance.
Pity these Scooby-Doo and mini-van drivers. But if your out on a bicycle, take care too.