On Absurdly Poor Criticism And Advocate Misconduct, Part One

On September 14, 2013, exactly a month before I started writing this post, I was contacted by a colleague who expressed an interest in changes in behavioral practice since Lovaas's original methods and models of clinical treatment.

During the resulting exchange, I attempted to explain a variety of things related to behavior analysis, ranging from how ABA is not a treatment method to the relationship between ABA and PBS (the short version is that PBS is a brand-named philosophy regarding how to go about conducting and using ABA research). I also provided her with a number of assorted articles and writings on the subject, including a piece of my own work which acted as an overview.

I ended the exchange on something of a positive note, hoping that the information would help. The positive note, however, did not last.

This is what she wrote... or, at least, the currently-published version. There has been a rather spectacularly intellectually dishonest edit in the interim. It's, to put it mildly, an extraordinarily poor critique. The arguments are, by and large, spectacularly off-base, and her abuse of my writing is glaringly obvious (if not as much so as before the edits).

That said, I should probably discuss what this means and why it's a problem before I get into a detailed critique of the piece itself.

Contrary to what some people apparently believe, saying that a critique is poor does not mean that one disagrees with its conclusions or that the critique does not deal with real problems. It is saying that the critique misidentifies the issues involved and/or argues from a position of misunderstanding or prejudice.

In this case, the author is attempting to argue that all forms of applied behavior analysis are inherently unethical -- a very, very strong conclusion, one that simply does not follow from the evidence (such as it is) and arguments (such as they are) that she presents. Saying so isn't defending ABA, and certainly isn't excusing, justifying, or apologizing for the assorted abuses with which people have valid complaints.

This is important for several reasons -- not the least of which is that poor criticism serves to distract from real issues, detracts from good criticism, and confuses issues in ways that impair efforts to reform things.

To illustrate this, let's take a very different example, one that most of us can rapidly identify, easily understand, and generally make easy sense of: one of the more disgusting things which occurs whenever news story publishes a story about a black man raping a white woman.

Rape is obviously wrong: it's a gross violation of  a woman's bodily autonomy, a dehumanizing act which can easily (and often does) destroy her life. It is very difficult to think of a worse violation of someone's personhood... and the ethnicity and skin color of perpetrator and/or victim is utterly irrelevant to this.

Unfortunately, however, some people insist on making the moral issue here about race in a variety of ways. One of the simpler (and more vile) of these is to simply state that the act was wrong because a man like that (a black man, not a rapist) has no business sexually touching a White woman.

This is an absurdly poor (and racist) criticism of rape. It is one that needs -- urgently -- to be shouted down and combated whenever it pops up.

Referring to this sort of thing as poor discussion or off-base criticism is very much not excusing the heinous criminal act to which the alleged criticism was directed. It is simple truth.

The race thing serves to distract from the real problem. To the extent to which it gets attention, it's distracting people from paying that same attention to other, more relevant, criticisms.

But... let's say that some people actually took it seriously. Let's further say that they then tried to use it as the basis for political reform efforts.

These efforts would be useless at best and harmful at worst. In fact, that particular criticism can pretty much be considered a form of rape apology in and of itself: if the rape of a white woman by a black man is only heinous because of the race difference, what's wrong about a white man raping a white woman?

More, such "reform" efforts would likely target and harm completely innocent interracial couples. In fact, such prejudices and acts have historically caused very substantial harm in the form of blatantly racist legislation and various racial prejudices for just this reason.

Obviously, this has little directly to do with the ABA article which started this discussion, but does serve to illustrate a few very important points: 1) poor criticism is rarely helpful; 2) poor criticism is often harmful, even when its conclusions may be correct... and 3) stating that an argument is poor is not the same thing as stating that its conclusion is wrong.

In Part Two of this series, I will hopefully get to precisely why the specific critique that started this is poor and unlikely to be helpful. In Part Three, I will discuss just why I'm taking such pains to lay out these problems, why a simple blog post like that has lead to me starting an extended blog-rant, just what followed from the situation, and why it's taken me so long to post all of this.

On Diagnosis

In most of medicine, the term "diagnosis" refers to the process by which a doctor (ideally) determines what disease process is underlying a patient's symptoms, as well as the determination itself. To clarify the relationship between the two meanings: diagnosis is the process by which the doctor provides the patient with a diagnosis.

Because diseases are abstractions based on cause (or "etiology" in medical language), a diagnosis serves as an explanation of the symptoms involved. This might sound rather sophisticated and/or complicated, but it's really not. If you go to the doctor's office and complain that your stomach hurts, "indigestion" is an explanation because it refers to a causal process (that is, why your stomach hurts). Were the doctor to use an abstraction based on symptomology (such as "stomachache"), it would not.

Of course, the doctor's explanation for the symptoms can be wrong. Throughout most of medicine, this is referred to as "misdiagnosis". There are also syndromes and the like which we don't know the causes of and times when the doctor can't figure out what's going on. While we know some things about these syndromes and cases (e.g. epilepsy tends to be chronic problem), these "diagnoses" aren't explanations of the symptoms -- they're descriptions of them.

Once you get it, this is really pretty simple. An answer to the question of why your symptoms exist (in more technical language, an "etiological construct") can explain them; a description of the symptoms themselves (in more technical language, a "symptomolgoical construct") can't. Despite this, however, people often make this mistake in a wide variety of ways. There's even a formal name for doing so: "nominal fallacy".

Put yet another way, you cannot say that your stomach hurts because you have a stomachache. "Stomachache" is a symptomological construct -- a label for the stomach pain. You cannot say that you are having difficulty sleeping because you have insomnia. The statement that you "have insomnia" is simply another way of saying that you have trouble sleeping. Neither serves as an explanation. This isn't to say that terms and concepts like "stomachache" or "insomnia" can't be useful, but they can't answer most questions of "why"... because they have nothing whatsoever to do with cause.

I'm making this as clear as possible because there is one field of medicine where the definition of the term "diagnosis" I provided does not apply. That field is psychiatry.

"Mental disorders", as used in psychiatry, are not etiological constructs. They are symptomological constructs. To use my earlier analogy, they are not akin to "indigestion" and are more akin to "stomachache". When a psychiatrist "diagnoses" a mental disorder, they are emphatically not saying anything about the cause of the symptoms you present them with -- they are simply deciding how to describe those symptoms in the standardized and highly formalized language of psychiatry.

The psychiatric "diagnosis" of "major depressive disorder" is simply another way of saying that someone is depressed... only it's far more precise (among other things, it distinguishes "major depression" from less severe or more transient types of depression). The psychiatric "diagnosis" of "bipolar disorder" basically means that someone goes through 'episodes' during which his mood is different from normal (in a clinically significant way). Similarly, the psychiatric "diagnosis" of "autism" basically means that someone isn't following the developmental psychologists' often-bigoted (and why I call it that is a whole 'nother blog post) One True Developmental Path for human beings.

When looked at this way, the way that people tend to accumulate multiple psychiatric diagnoses is easily understood -- for many of the same reasons that I don't think people would be surprised to learn that people with stomachaches also have fevers much more frequently than people who do not. This is simply because fevers and stomachaches can be caused by many of the same things.

This does not, however, mean that "fever" and "stomachache" are the same thing. It also doesn't mean that it's appropriate to treat all people with stomachaches as if they also had fevers.

Moreover, the evaluation of "symptoms" in psychiatry is far more subjective and problematic than it is anywhere else in medicine. The problems with this are anything but simple, even if they're frequently ignored.

The easiest of these to resolve are simply matters of degree -- for instance, what constitutes "markedly diminished interest or pleasure in... activities"? Where do you draw the line between what's "markedly" diminished and what's just diminished?

For the most part, these represent a sort of diagnostic "fuzziness" which is... resolvable, albeit not necessarily easily. Statistical methods are pretty good at dealing with this sort of issue in a research setting, although the problem remains. It remains an obstacle, but hardly an intractable one. If this problem is not understood, however, it can create a very wide variety of misconceptions.

Other problems, however, are more noteworthy -- and fundamental. For one thing, the defining feature of a "symptom" in medicine is that it's viewed as an indicator of an underlying pathology. Stomachache is a symptom of indigestion because it provides evidence in support of the idea that you are having trouble digesting food. It provides this evidence because problems with digestion tend to cause stomachaches. "Stomachache", in general, is viewed as a symptom of disease because a stomachache is a pretty clear indicator that something is going wrong in the body (even if you don't know what, and even if the problem is fairly minor).

In other words, a "mental disorder" is a disorder because it is viewed as a sign that there is something wrong with the person who exhibits it. Our judgments of what constitutes something being "wrong" with someone, however, are notoriously problematic.

We human beings have a tendency to judge other people based on our expectations and our often-prejudiced personal (and/or cultural) views on what people should be. When people fail to live up to these, we tend to conclude that there's something wrong with them, rather than concluding that the problem was with our views and expectations.

For instance, homosexuality used to be a DSM mental disorder (and even though most sources will state that it was removed in 1973, this is not entirely accurate). Moreover, its official status as such has a long history of being used to justify the torture (via abusive "treatments") both of homosexuals and people judged as being "at risk for" homosexuality.

Then there's the rather infamous (and atrocious) example of the countless ways in which psychiatry and psychiatric diagnoses have been used as a tool of institutionalized racism and of racial oppression. We can even look at the ways in which attitudes about race have affected diagnostic patterns.

Then there's the issue of so-called "diagnostic redefinition", something which is rather hard to understand for people who don't understand that psychiatric disorders are symptomological constructs.

Diagnostic redefinition is relatively easy to understand if you look at approximate analogues involving symptomological constructs in the world of general medical practice. In this case, I'm going to use the construct of obesity for the purpose of explanation.

At present, obesity is most commonly defined in terms of something called "body mass index" (BMI) -- a calculated value based on height and weight. Neither BMI nor obesity, however, are etiological constructs -- they're descriptive constructs. In the case of obesity, it's a symptomological construct, presently defined by a BMI of thirty or higher (in most countries, anyway).

If, however, medical researchers were to find that a different cutoff point -- say twenty-five (which, incidentally, is the cutoff point in Japan) or thirty-five -- was more meaningful, the cutoff point would change to reflect this. If the cutoff point was lowered, a number of people would suddenly find themselves "obese" when they weren't before -- something which is called "broadening criteria" for obesity. If the cutoff point was raised, a number of people would find themselves no longer considered "obese", due to something called "narrowing criteria".

Note that nothing would really have changed with these people themselves. Only the terms used to describe them -- the label they receive, in other words -- would have changed. This is the essence of diagnostic redefinition in psychiatry.

Despite this, however, it's often nowhere near so simple -- especially when it comes to the DSM. It's quite common for criteria to broaden and narrow at the same time. This usually happens when rather than changing a numeric score to broaden or narrow criteria, the metric is changed or redefined.

To continue the analogy, if we were to find that some other measure of obeisity (e.g. total body weight, percentage body fat) was more meaningful than BMI, our definition of obeisity would shift to accomodate this. Obeisity would be redefined in terms of this new metric, and a number of people would suddenly "gain" or "lose" a "diagnosis" of obeisity without changing one whit themselves. The newly "diagnosed" or "undiagnosed" wouldn't have changed -- the language used to describe them would have.

This is precisely what happens every time a new edition of the DSM comes out. Sometimes it happens more often.

Note that none of this means that the "diagnosis" of "obesity" isn't useful or meaningful. None of it means that obesity isn't real (although if one is feeling particularly philosophical, one can point out that it's only a label or descriptor, and as such the phrase "for a certain value of 'real'" applies -- it's only "real" in the sense that "redness" is; similarly, "autism" is only real in the senses that "intelligence" is).

There are countless other problems with psychiatric diagnosis. Quite frankly, I'd write about them more, but this entry has been sitting half-completed for more than long enough already.

I just hope that this helps people understand certain matters and helps clear up some of the assorted confusion regarding the topic. Countless authors -- in academia, in the blogosphere, in the print media -- clearly don't understand a lot of what I try to explain above.

Hopefully, I did not just "try".

On Mental Disorders, Part One

One of the major errors that people make when thinking of DSM mental disorders and the like is to think of them as diseases. While this is undoubtedly true for some diagnoses in the DSM, the fact of the matter is that "mental disorder" and "disease" are really very different concepts.

While disease categories are abstractions based on etiology, mental disorders... well, aren't. That isn't even the ideal anymore.

As I discussed in an earlier post, certain conditions must be met for something to be called a disease:

• It must be an impairment of the normal state of the living animal or plant body or one of its parts.
• It must interrupt or modify the performance of the organism's vital functions.
• It must be typically manifested by distinguishing signs and symptoms.
• It must have a distinguishing etiology (which may be simple or complex).
  

The conditions for something being called a mental disorder, however, are very different. Unlike with the concept of "disease", however, these are anything but straightforward.

Going to MedLine Plus, for instance, yields the following definition: "a mental or bodily condition marked primarily by sufficient disorganization of personality, mind, and emotions to seriously impair the normal psychological functioning of the individual—called also mental illness."

In other words, while a disease is an abstraction based on etiology, a mental disorder is an abstraction based on symptoms. While a disease is a process which causes its symptoms, a mental disorder is a label which describes them or a description of them. Classification of mental disorders makes no reference to the why, only to the what. They have no explanatory value whatsoever; to say that a psychiatric diagnosis has any explanatory value whatsoever is to commit nominal fallacy.

Even this, however, isn't really satisfying. What, for instance, does "disorganization" mean? How do you decide whether or not something "impair[s] the normal psychological functioning of the individual"? Heck, just what does "normal psychological functioning" mean?

These questions are important because of the "wiggle room" built into these terms. In the DSM-I and II, for instance, homosexuality was considered a mental disorder -- homosexuals were considered "broken" heterosexuals whose attraction to members of their own sex represented an impairment to their functioning qua members of their gender. Another infamous example of this problem featured a doctor who pathologized the desire of slaves to flee their masters (he considered whipping to be curative).

My abnormal psychology textbook provides a somewhat more clear answer: it defines one as "a psychological dysfunction within an individual that is associated with distress or impairment in functioning and a response that is not typical or culturally expected." (p. 2)

This, in turn, breaks down into four parts. To qualify as a mental disorder, a set of symptoms must:

• Constitute a "psychological dysfunction".
• Be within the individual.
• Be associated with distress and/or impairment in functioning.
• Be associated with (at least one) response that is not typical or culturally expected.

Unfortunately, none of these is quite what it seems. I'll write more on this later, but for now... just keep in mind: a mental disorder is not a disease.

Edit: Corrected an embarassing typo.

I Always Want to Be Right (And You Should, Too)

I always want to be right. When I say this, I don't mean that I want to win arguments. That's not being right -- that's having other people tell you you're right. I mean that I want my beliefs to reflect reality. I want all of my beliefs to reflect reality -- if not perfectly, then at least as fully and completely as possible.

I do not want to believe I can fly when I can't. The practical consequences of this are perhaps best described by the term "splat".

I do not want to believe that a cure for cancer works when it doesn't. The practical consequences of this are paid in wasted money and unnecessary side effects. By the same token, however, I don't want to believe that a cure doesn't work when it does. The practical consequences of this are commonly referred to as "dying in horrific agony". Selecting an effective (and helpful) treatment or cure is one of the hardest -- and most important -- parts of medicine.

I do not want reality to conform to my existing beliefs. That idea -- the foolish wishing for what I tend to derisively call "magic god powers" -- may make for a nice fantasy on occasion, but is usually a waste of time. I want my beliefs to conform to reality. I want to believe what is true, not for reality to follow from what I believe.

I do not want others to sit back and say nothing when I express an inaccurate belief. If they do so, I lose the opportunity to correct my beliefs. I fully understand that the price of being right is admitting that you have been wrong. I accept and eagerly pay this price. Metaphorical humble pie may taste awful, but it's very good for you.

I do not want others to hold back in debate. I want to hear the best, most valid arguments that the people I'm debating can put forth -- and I want them to support these arguments as well as they can. I, in turn, will do the same. I will hold my position with the best arguments I can come up with (as the circumstances allow) in hopes of drawing out the best, most thorough counterarguments possible. If I did otherwise, I would deprive myself of evidence and reasoning that could help me develop a better, more informed view of the issue we're debating. If I "win", so be it. If I "lose", so be it. Either way, I'll be using the reasoning and evidence to reevaluate my position... and will very often change it.

Of course, this changing isn't always obvious. I usually reevaluate my position after the debate... and I often play "devil's advocate", offering forth arguments that I don't really believe (but can't easily counter) in order to draw out a precious -- and useful -- counterargument.

I don't want to reach premature final judgment... and my beliefs tend to be more probability estimates regarding the possibility of something being true than actual beliefs that something is true. Truly wanting to be right means being comfortable with the limitations of one's knowledge.

And, in the end, as I reflect on my attitudes and my desire to be right... I can't help but think that the world would be a better place if more people desired to be right, too.

"Words to the Wise"

As I write this, I am sitting in a computer lab with a copy of Thomas Szasz's "Words to the Wise". It's an utterly fascinating collection of quotes and sound-bites on a wide-ranging collection of topics by one of the most controversial authors in the field of clinical psychology. Some of the quotes I agree with; others I don't. All, however, are thoughts worth considering. Despite the format, it's one of the most thought-provoking books I've seen in a long time.

Ten of the quotes more relevant to today's autism issues:

If a person ingests a drug prohibited by legislators and claims that it makes him feel better, that proves that he's an addict.

If he ingests a drug prescribed by psychiatrists and claims that it makes him feel better, that proves that mental illness is a biomedical disease.

When and why do we say that a behavior is caused rather than willed?

We say that chemicals in the brain cause depression and suicide; but we don't say that chemicals in the ovaries or testicles cause lust and marriage.

The child cannot match the adult in most accomplishments. Hence, we reward him for effort as well as achievement. Yet, the child must learn that what counts in life is not effort but achievement. The child over-rewarded for effort may grow up to seek approval for trying instead of for succeeding. This dooms him to failure. If he succeeds, he succeeds only at trying hard. If he fails, he fails miserably.

When a woman finds having a fetus in her body annoying, she can abort it by taking an abortifacient drug or having a surgical abortion.

When a woman finds having a child in her home annoying, she can abort his persona by having a child psychiatrist give him a chemical straitjacket.

Diagnoses are not diseases.
Diagnoses are names, human fabrications.
Diseases are phenomena, facts of nature.

Demonstrable bodily lesion is the gold standard of medical diagnosis. Without practical convertability into gold, the value of paper money rests only on faith. Without conceptual convertability into bodily lesion, the diagnosis of disease rests only on faith.

A patient with cancer says: "If I had refused my surgeon's suggestion that I have my tumor removed, the cancer would have killed me."
A patient with depression says: "If my psychiatrist had let me refuse the electroshock treatment he recommended, I would have killed myself."
The difference between these two sentences sums up the difference between bodily illness and mental illness.

Three principal rules of conduct:

1. The Golden Rule: Do onto others as you want them to do unto you.

2. The Rule of Respect: Do unto others as they want you to do unto them.

3. The Rule of Paternalism: Do unto others as you in your superior wisdom know ought to be done unto them in their own best interests.

Formerly, debasing the Other by calling him a "nigger" was considered politically correct: the speaker was viewed as a protector of the race or nation from those bent on defiling it.
Today, debasing the Other by calling him "sick" is considered politically correct: the speaker is viewed as a protector of the debased person's best mental health interests and of the nation from a danger to the public health.
Replacing the former rhetoric by the latter is considered moral progress.

Today, everyone claims to be working for the patient's best interests. No wonder the patient is in deep trouble.

Note that I selected these quotes based on relevance, not agreement. I don't, as a matter of fact, agree with a lot of Szasz's thinking. This said, he's an incredibly thought-provoking author. In this blog post, I'm not going to take a stance on any of these. Instead, I'm going to give an "assignment" of sorts to each of my readers.

Read these quotes. Think about them. What does each of them mean? What do they imply? Is this statement -- or implication -- accurate? Is Szasz right or wrong? Why?

Then post an explanation here, answering at least one of these questions for at least one of these quotes. Feel free to do so anonymously or pseudonymously. I don't care about that (although I will delete SPAM posts or personal attacks). If you aren't the first to reply to this, also reply to at least one of the previous replies.

My own replies here will be mostly playing "devil's advocate", issuing responses also intended to make people think and facilitating discussion. Unless I state specifically that a position is my own personal belief, please don't think that it is. I will likely issue arguments against your position even if I agree with it.

The point, after all, is to get people thinking about this sort of thing.

In addition to the obvious, this exercise should give you a pretty good idea of why I highly reccommend this book. It has nothing to do with agreement (although I strongly agree with both the contents and sentiments of many of the quotes, this cannot be said about many others). It has everything to do with the way the book makes you think.

Oh, and it's a treasure mine for anyone who wants quotes for articles, the beginnings of book chapters, and the like. Lots of grade-A quotes here... which is the entire point of the book.

Edit: Added a link.