I’ve spent decades in magnetic resonance research and since 1980 my colleagues and I have been studying the human brain. Like many fields of science, it is astounding to reflect on the progress made in the uses of magnetic resonance which has gone from being a physicist’s means of studying the nucleus to an omnipresent tool for clinical medicine and biological research, especially in neuroscience. Our society holds great hopes for brain research. The Obama administration recently announced a “Brain Activity Map” project that would seek “to advance the knowledge of the brain’s billions of neurons and gain greater insights into perception, actions, and ultimately, consciousness.” However, the work that my colleagues and I have done to understand brain metabolism and function argues that some of the enthusiasm shown for these methods needs a fundamental re-examination.

In essence, I have seen too much scientific work that starts with assumptions that we know and have a solid and consensus-driven understanding of concepts like memory or consciousness when in fact we do not and cannot. Countless tests of “memory” that track activated areas of the brain via fMRI have abandoned scientific observation and induction in favor of a priori assumptions about words or ideas that have value during common usage but are not empirical concepts. What we now know about consciousness from brain imaging is that certain measurable brain properties, such as the total neuronal energy consumption, are necessary for the person to be in the state of consciousness as defined by the anesthesiologist during surgery. As more properties, including brain activities, necessary for a person to be in the state of consciousness are uncovered, the better we will understand it, but we will not get there by trying to define that elusive intangible called consciousness.

Image Credit: Brain MRI, 60M. Photo by © Nevit Dilmen, Creative Commons via Wikimedia Commons.

While there are marvelous results to be gained from careful research on brain metabolism and blood flow as measured by fMRI, there is little to be gained by making assumptions about the human mind. We shouldn’t leap from early but exciting understanding of brain activities necessary for a person’s behavior to assumptions about mental processes presumed to underlie those behaviors. Once we are trained to do things reproducibly — like recognizing a face or avoiding a moving automobile — brain activity supports our response. While we (as scientists) know a lot about how the muscle receives electrical impulses, we would never assert that the biceps, triceps, and deltoids lift a bride over the threshold after a wedding — the groom does. Even as we learn, with astounding precision, about which areas of the visual cortex are activated when the person learns to differentiate between cars and vases, we should not assume that the brain makes this distinction. It is the person who decides and acts; it is the organ — the muscle or brain — that supports her behavior.

One can postulate many reasons for society’s enthusiasm to translate basic research into useful applications in health and control. Nevertheless, it is dangerous for a subtle collective willingness among research scientists to replace traditional scientific methods that are producing wonderful descriptions of the brain’s support of observable behaviors with claims of having found a physical basis for mental concepts like working memory or attention.

Thomas Nagel’s recent book offers a very clear lens for this approach. He proposes that science has failed as an epistemological method because material science cannot explain the mind. Nagel argues that the mind obviously exists, and since chemistry and physics can’t explain it then science has failed and we must look for alternate epistemologies. I certainly agree that physical science cannot explain mind but I would depart from Nagel’s solution for two important reasons. While he defines physical science as proposing to explain everything, the more realistic and generally held view is that science is capable of understanding some aspects of the world but not necessarily all. We can’t combine the subjective views of the mind held by literature, psychology, philosophy, and everyday life with measurements of neuronal activities to give us a scientific, objective, or complete description of mind. However this is a failing of material science only if one holds a nineteenth century view that material science can explain everything in the world, a view discarded when the limits of classical physics were revealed by quantum mechanics and relativity.

As Neils Bohr succinctly observed “Physics does not tell us what nature is but rather tells us what we can say about nature.”

Robert G. Shulman is a biophysicist who has pioneered the use of nuclear magnetic resonance (NMR) and other spectroscopic techniques in physics, biochemistry, and brain imaging. He is the author of Brain Imaging: What it Can (and Cannot) Tell Us About Consciousness. His original studies created active fields of investigation in all these disciplines. He is the Sterling Professor (Emeritus) of Molecular Biophysics and Biochemistry at Yale University where he formed the Magnetic Resonance Center, taught Biochemistry, Biophysics, and Literature, and was Director of the Division of Biological Sciences. He is a member of the National Academy of Sciences and of the Institute of Medicine.

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There is currently extensive use of complementary and alternative medicine (CAM) — also known as integrative or mind-body medicine — in the United States to sustain well-being in both aging baby boomers and in children and adolescents. The National Center for Complementary and Alternative Medicine (NCCAM) defines CAM therapies as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine,” with “conventional” medicine being defined as the approaches used by clinicians in the routine daily practice of Western or allopathic medicine that are within the currently accepted standard of care.

The most recent comprehensive assessment of CAM use in the United States found that roughly 40% of US adults had used at least one CAM therapy within the past year. In addition, Americans make more visits to CAM providers each year than to primary care physicians and spend at least as much money on out-of-pocket expenses for CAM services as they do for all conventional physician services combined. Patients with mental disorders turn to CAM for relief of symptoms of anxiety, mood, insomnia, impaired cognition, and perceived stress. The most commonly used CAM techniques include prayer for health and the use of multivitamin supplementation. Given widespread use of CAM services among patients, there is an urgent need for greater awareness and familiarity with its applications and outcomes.

As baby boomers age and increase use of CAM, mental health professionals require a working knowledge of CAM techniques intended to address late life mood disorders. An estimated 33-88% of older adults will use CAM therapies, including those with late-life depression and bipolar disorder. CAM treatments of mood and anxiety disorders include acupuncture, deep breathing exercises, massage therapy, meditation, naturopathy, and yoga.

Complementary and alternative medicine encompasses a number of techniques collectively known as mindful exercise (e.g. yoga, Qigong, and Tai Chi), or meditation. This ‘physical exercise executed with a profound inwardly directed contemplative focus’ is increasingly utilized for improving psychological well-being. In general, mindful physical exercise contains the following key elements:

1. a non-competitive, non-judgmental meditative component,
2. mental focus on muscular movement and movement awareness combined with a low to moderate level of muscular activity,
3. centered breathing,
4. a focus on anatomic alignment (i.e., spine, trunk, and pelvis) and proper physical form,
5. energy centric awareness of individual flow of intrinsic body energy, otherwise known as prana, life force, qi, or Kundalini.

Mindful exercise has been shown to provide an immediate source of relaxation and mental quiescence. Scientific evidence has shown that medical conditions such as hypertension, cardiovascular disease, insulin resistance, depression, and anxiety disorders respond favorably to mindful exercises.

There is a growing database of the physiological effects of mindful exercise and meditation. Tai Chi and Qi Gong have been shown to promote relaxation and decrease sympathetic output, and to benefit anxiety, depression, blood pressure, and recovery from immune-mediated diseases. Tai Chi and Qi Gong have been shown to improve immune function and vaccine-response. These practices have also been shown to increase blood levels of endorphins and baroreflex sensitivity, and to reduce levels of inflammatory markers (CRP), adrenocorticotrophic hormone (ACTH), and cortisol, implicating the hypothalamic-pituitary-adrenal (HPA) axis as a mediator of stress and anxiety reduction. Brain wave or electroencephalopathy (EEG) studies of participants undergoing Tai Chi and Qi Gong exercise have found increased frontal EEG alpha, beta, and theta wave activity, suggesting increased relaxation and attentiveness. These changes have not been found in aerobic exercise controls.

Yogic meditation (Kirtan Kriya) for stressed family dementia caregivers resulted in lower levels of depressive symptoms, and improvements in mental health and cognitive functioning. Participants in the yogic meditation group showed a 43% improvement in telomerase activity after 12 minutes of daily practice for 8 weeks, compared with 3.7% in relaxation music control participants. This suggests that brief daily meditation practices can benefit stress-induced cellular aging. Kirtan Kriya reversed the pattern of increased NF-κB-related transcription of pro-inflammatory cytokines, and decreased IRF1-related transcription of innate antiviral response genes in distressed dementia caregivers. This reinforces the relationship between stress reduction and beneficial immune response. In the same study, nine caregivers received brain FDG-PET scans at baseline and post-intervention. When comparing the regional cerebral metabolism between groups, significant differences over time were found in different patterns of regional cerebral metabolism suggesting brain-fitness effect different from passive relaxation.

Studies of meditation also report decreased sympathetic nervous activity and increased parasympathetic activity associated with decreased heart rate and blood pressure, decreased respiratory rate, and decreased oxygen metabolism. Functional neuroimaging studies have been able to corroborate these subjective experiences by demonstrating the up-regulation in brain regions of internalized attention and emotion processing with meditation.

In a recent systematic review of neurobiological and clinical features of mindfulness meditations, Chiesa and Serretti (2010) provided evidence on the neurobiological changes related to Mindfulness Meditation (MM) practice in psychiatric disorders. Meditation practices that focus on concentration of an object or mantra seem to elicit the activation of fronto-parietal networks of internalized attention; meditation techniques that focus on breathing may elicit additional activation of paralimbic regions of insula and anterior cingulate; and meditation techniques that focus on emotion may elicit fronto-limbic activation. Future studies will be needed to disentangle the brain activation patterns related to different meditation traditions.

Given the noninvasive nature of mindful exercise and meditation, these exercises are an appropriate option for consumers and clinicians, particularly for conditions that have been examined in controlled studies. Significant evidence supports the assertion that Tai Chi and Qi Gong and yoga and meditation can improve physical and mental health, and quality of life. Ethical considerations should be taken into account when practicing or recommending spiritual interventions by healthcare professionals to respect patients’ beliefs in choosing mind-body interventions.

Dr. Helen Lavretsky is a Professor of Psychiatry at the Semel Institute for Neuroscience and Human Behavior at UCLA, a geriatric psychiatrist with the research interest in geriatric depression and caregiver stress, as well as complementary and alternative medicine and mind-body approaches to treatment and prevention of disorders in older adults. She is co-editor of Late-Life Mood Disorders with Martha Sajatovic and Charles Reynolds. She is a recipient of the two Career Development awards from NIMH and other prestigious research awards. Her current research include clinical and translational studies of geriatric depression and caregiver stress, as well as complementary and alternative interventions for stress reduction in older adults.

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The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification of all diagnoses given to patients by mental health professionals. Since the publication of the third edition in 1980, each edition has been a subject of intense interest to the general public. The current manual, DSM-5, is the first major revision since 1994.

DSM-5 is not, as sometimes claimed, “the bible of psychiatry”. It is not based on a thorough understanding of the causes of mental disorder, which remain largely unknown. Nor does it provide guidance concerning treatment. What DSM does is to allow mental health professionals to communicate with each other by listing criteria by which diagnoses can be made reliable.

When DSM-5 was in the planning stage, there was talk of radical changes, leading to a “paradigm shift”. This did not happen, as the scientific reviewers of proposals for revision insisted that major changes could not be made without very strong scientific evidence. A few changes attracted attention in the media (such as allowing a diagnosis of depression in people suffering from grief). By and large, the manual is not that different from its predecessors.

The problems with DSM-5 are the same as those affecting all earlier editions. If we do not understand what causes mental illness, it is very difficult to classify it. Unfortunately, the use of certain diagnoses is so widespread that people get the impression that categories in psychiatry are as real as hepatitis or multiple sclerosis. They are not. They are simply convenient ways of describing what clinicians see in practice. None of them have a correlation with biomarkers such as blood tests, genes, or brain imaging. They remain entirely dependent on signs and symptoms, which is all that mental health practitioners can currently observe.

The DSM system has led to an inflated prevalence of certain disorders, sometimes producing diagnostic epidemics. These problems affect some of the most common disorders in practice. Thus “major depression” is a very disparate collection of signs and symptoms that cannot be used to determine the correct treatment. Bipolar disorder is being diagnosed in patients who do not have its classical features, and has even been applied to young children. Attention deficit hyperactivity disorder (ADHD) has no definite boundaries, and is being greatly over-diagnosed, both in children and adults. Autism spectrum disorders, once considered rare, are now being seen as among the most common of all conditions that professionals see.

The real problem behind diagnostic epidemics is the failure of the DSM system to distinguish between mental disorder and normality. There is no agreed on definition of mental illness, whose scope has been steadily expanded. This trend is associated with a dangerous over-prescription of drugs that were originally developed for patients with severe and clearcut illnesses.

The DSM system can be described as flawed but necessary. Clinicians need to communicate to each other, and even a wrong diagnosis allows them to do so. However it will require many decades before we know enough about mental illness to produce a truly scientific classification.

Joel Paris is a professor of psychiatry at McGill University (Montreal, Canada), and a research associate at the SMBD-Jewish General Hospital, Montreal. He is the author of 15 books, most recently The Intelligent Clinician’s Guide to the DSM-5®, and 183 peer-reviewed scientific articles.

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch today, 18 May 2013. Read previous posts: “DSM-5 will be the last” by Edward Shorter, “The classification of mental illness” by Daniel Freeman and Jason Freeman, “Personality disorders in DSM-5″ by Donald W. Black, and “American psychiatry is morally challenged” by Michael A. Taylor.

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The fundamental problem with American psychiatry is American psychiatrists. It seems every few months there’s fresh news about some well-known academic psychiatrist paid boatloads to endorse a new treatment that doesn’t work—or worse—causes harm. Among the 394 US physicians in 2010 who received over $100,000 from the pharmaceutical industry, 116 were psychiatrists, well out of proportion of the percentage of psychiatrists in medical practice. The American Psychiatric Association is also heavily supported by the drug industry. Its annual meetings, once efforts to educate members, are now basically week-long infomercials for Big Pharma. This influence has seeped into clinical trials as well, where study design is carefully manipulated by industry representatives to favor their new product. In turn, companies analyze their data out of view of academics, sequestering data unfavorable to their product, and ghostwriting journal articles for academics.

In similar fashion, fancy devices have been introduced with claims of wondrous benefits, none of which have materialized. Light-emitting boxes, for example, were supposed to be the next great psychiatric advent to prevent winter depressions, but the evidence for this claim is still weak. Similarly, vagal nerve stimulation (an implanted electronic pacer in the chest with electrodes attached to a nerve in the neck) was supposed to relieve treatment-resistant depressions. Yet it offers no demonstrated benefit and costs the poor soul subjected to it about $20,000 out of pocket. Transcranial magnetic stimulation, a ring-shaped magnet that delivers a magnetic pulse to the head, was going to replace electroconvulsive therapy. At best it has a placebo effect. And yet, these treatments continue because of their support by psychiatrists, many of whom have a vested interest in the success of the products. Integrity, it seems, is the only thing in short supply for psychiatry these days.

Just like the new antidepressant and antipsychotic drugs that have been introduced in the past three decades, the idea behind these new treatments was simply to make money. In 2006, US sales alone for these new gadgets topped 289 billion, and continue to rise. Between 1998 and 2006, the industry spent 855 million dollars on lobbying—a total which exceeds that of all other lobbies—to keep that momentum rolling.

You can’t fault the desire to make money; it’s the American way. But when treatments are equated to widgets, profits will always trump concerns of efficacy and safety. Can you think of an industry in which that has not been the case? Sadly, this was not always the situation with psychiatry. The early psychiatric drugs were developed by industry and psychopharmacologists working in concert, striving toward the production of effective and reasonably safe agents. And they succeeded. The older and less expensive antidepressants and antipsychotics are still just as good as or better than the new agents. In fact, the cost to patients drops from 18% to 6% of their medical dollar when they switch from patented to generic medications.

The new psychiatric drugs and novel treatments are frauds. The evidence that they work is weak and is often distorted to the point of fabrication. Studies show that the new antidepressants (e.g., Prozac, Paxil, and Citalopram) achieve remissions at only slightly better rates than a placebo. The widely prescribed anticonvulsant valproic acid (Depakote) outpaces lithium in prescriptions as a mood stabilizer, and yet it’s not as effective. That’s because the guidelines for psychiatric drug treatments are written by academics paid out of the pocket of Big Pharma. These guidelines are required reading in residency training and dictate the diagnostic and treatment decision-making of most psychiatrists, but really they’re just cookbooks, following the bottom line not the data. The most recent version of the DSM, for example, was drafted by academics, many of whom continue to receive substantial financial support from the industry. This clear conflict of interest in part accounts for why the thresholds for illnesses in the manual continue to get lower and lower: if more people are “ill,” it justifies the prescription of more psychotropic medication. Thus perpetuating the whole corrupt cycle.

Over the past half-dozen years, academic psychiatry has started to wean itself from the pharmaceutical milk-cow. Drug “reps” are restricted at most medical centers now, and direct payments to departmental activities are increasingly limited. These are good first steps, but financial support to departments still occurs. Multisite clinical trials are still industry affairs. The well-known psychiatrists and experts crafting treatment guidelines and new versions of the DSM are still industry supported. Despite the financial pain that might ensue, the only solution is to end the relationship. No academic responsible for the training and mentoring of medical students and young physicians should accept any industry money. They already receive adequate financial support from their institutions. If the industry wants its products tested, unrestricted grants can be given to the institution, which can then monitor the use of the funds for a small overhead fee as is done in the case of other funding sources. No more industry-designed and analyzed research. No more hidden unfavorable data. No more industry-supported lectures. No more direct industry support of any kind. This way, even if we make mistakes, our medicine will at least have integrity.

Michael A. Taylor, MD, is the author of Hippocrates Cried: The Decline of American Psychiatry. He works as an adjunct clinical professor of psychiatry at the University of Michigan Medical School. He was founding editor of the peer-reviewed journal, Cognitive and Behavioral Neurology, and also worked as professor, chairman, and director at the Department of Psychiatry and Behavioral Sciences at the Chicago Medical School. He established and directed the psychiatry residency-training program at the State University of New York at Stony Brook.

Oxford University Press is running a series of articles on psychiatry and the DSM-5 in anticipation of the launch of the DSM-5 at the American Psychiatry Association meeting on 18 May 2013.

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for a view from Joel Paris. Read previous posts: “DSM-5 will be the last” by Edward Shorter, “The classification of mental illness” by Daniel Freeman and Jason Freeman, and “Personality disorders in DSM-5″ by Donald W. Black.

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Those of us in the mental health professions anxiously await the release of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Others may wonder what the fuss is about, and may even wonder what the DSM-5 is. In short, it is psychiatry’s diagnostic Bible. While some imbue it with the reverence given a religious tract, it is not inerrant and only reflects the collective wisdom of those entrusted with the charge of revising it. The current manual, DSM-IV, came out in 1994 with a text revision in 2000, so in some ways the march to DSM-5 has been a 19 year journey.

As a psychiatrist, I am interested in classification, but I am particularly interested in how antisocial personality disorder, or ASP, has been classified over time. Over the past 200 years, ASP has been consistently recognized as one of the most identifiable and important of the psychiatric disorders, whether called manie sans délire, moral insanity, or even psychopathic personality. These terms all describe, at their most fundamental, bad behavior unconnected to medical illness or psychosis. During the DSM-5 deliberations, I and others became concerned that the committee dedicated to discussing personality disorders (the Personality and Personality Disorders Work Group) might decide to ditch the current diagnostic criteria and replace them with a combination of new diagnostic criteria and a “dimensional,” rather than categorical, evaluation of various personality traits.

The DSM-5 deliberations, for the most part, took place quietly and behind closed doors by clinicians and researchers who devoted many hours to their deliberations. They were tasked with considering the literature, research advances, and the users and patients’ needs when recommending changes to a diagnosis. Having watched the process as an interested observer, I can say that it was — for the most part — open, transparent, and free of conflicts of interest, despite loud and strident complaints from some quarters. Yet the Personality and Personality Disorders Work Group still produced a plan deemed by many as unworkable and overly complicated. This new plan was rejected by the leadership of the American Psychiatric Association in December 2012. The Personality and Personality Disorders Work Group was the only committee involved with the DSM-5 revision process in which two members openly and publicly resigned. No other work group had its many years of work rebuked.

So what went wrong? My own belief is that the work group overreached. In response to researchers on the committee whose life’s work was to understand and test dimensional schemes for describing personality traits, the committee wed itself to developing a scheme to replace the existing criteria for personality disorders. They came up against considerable pushback. I believe they never fully grasped that psychiatrists and many other clinicians tend to think categorically (is trait ‘x’ present or not?), rather than dimensionally (how much of trait ‘x’ is present?), and are very concerned with insurance reimbursement (would an insurer pay for the care of someone with some, but not all, of these traits?). The scheme itself appeared overly time consuming to busy practitioners; instead of simply deciding on a diagnosis, they might have to rate up to 5 personality ‘domains’ and 25 trait ‘facets’. Many clinicians, too, were concerned that some of the personality disorders that are well-researched and whose criteria were known to be valid (antisocial and borderline personality disorders, for example) would be changed for no good reason. In my view, the committee members have only themselves to blame for what proved to be an embarrassing turn of events. To preserve comity, the American Psychiatric Association leadership agreed to place the new scheme in the appendix of DSM-5 so as to be available to researchers and clinicians.

So, to those who wonder what has happened with antisocial personality disorder in DSM-5: the answer is nothing. After all those hours of deliberation and discussion, the criteria set for ASP, and all the other personality disorders, in the DSM-5 is exactly the same as it was in DSM-IV.

Donald W. Black, MD, is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy), Revised and Updated Edition. He is a Professor of Psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City. A graduate of Stanford University and the University of Utah School of Medicine, he has received numerous awards for teaching, research, and patient care, and is listed in “Best Doctors in America.” He serves as a consultant to the Iowa Department of Corrections. He writes extensively for professional audiences and his work has been featured in television and print media worldwide. Read his previous blog posts.

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for views from Michael A. Taylor and Joel Paris. Read previous posts: “DSM-5 will be the last” by Edward Shorter and “The classification of mental illness” by Daniel Freeman and Jason Freeman.

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According to the UK Centre for Economic Performance, mental illness accounts for nearly half of all ill health in the under 65s. But this begs the question: what is mental illness? How can we judge whether our thoughts and feelings are healthy or harmful? What criteria should we use?

This month sees the publication of the latest version of the psychiatrist’s bible: the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is arguably the definitive reference work on mental illness, used by health services worldwide (though the World Health Organisation’s International Classification of Diseases and Health Related Problems is widely used in the UK). Sales of the previous edition, DSM-IV, are estimated at about a million copies — not bad for a book that runs to almost 1000 densely packed pages and retails for around £80.

What’s changed in DSM-5 — apart from the move from Roman to Arabic numerals in the title? Well, terms have been revised (“mental retardation” has become “intellectual disability”, for example). New disorders have been introduced. For instance, “premenstrual dysphoric disorder” has been added to the list of depressive disorders. And, perhaps most controversially, some professionals have worried that the threshold for diagnosis of certain disorders appears to have been lowered — meaning that more people may be classified as mentally ill. Indeed there is organised opposition to the new edition, exemplified by the International DSM-5 Response Committee.

The DSM’s basic approach, on the other hand, has remained consistent for more than 30 years: a painstaking enumeration of symptoms, designed to make the clinician’s task of diagnosis easier and more consistent. This is an objective that it has undoubtedly achieved. But are those diagnoses scientifically valid?

Take clinical depression, for example. Nine possible symptoms are listed in DSM-IV, and you’d need to report at least five of them to warrant a diagnosis. These symptoms must be sufficiently intense to really interfere with a person’s life and they must have lasted for a while.

One effect of this approach is to emphasize the severe end of a spectrum that also includes relatively mild psychological problems. So the DSM criteria won’t capture everyday fluctuations in mental health. And they won’t pick up people with, say, four symptoms rather than five.

Implicit here is a debate about the nature of mental illness. The DSM uses a medical model of psychiatric illness. It thinks in terms of separate, discrete disorders, just like physical medicine. The approach is binary: either you meet the criteria for a particular condition, or you don’t.

Many would argue that this kind of all-or-nothing attitude, with hundreds of separate conditions, doesn’t fit well with people’s real-life experience of psychological problems. Better instead to think of psychological experience as being dimensional — that is, encompassing a wide variety of experiences, from the unproblematic to the severely distressing. The further along that dimension, the more symptoms a person is likely to have and the more upsetting and disruptive those symptoms will be.

This is the psychological model of mental illness. It argues that there’s no binary opposition between disorder and ‘normality’. Psychological disorders are simply the extreme manifestation of traits that we all possess to varying degrees. For example, almost everyone experiences occasional feelings of anxiety. People who develop what the DSM classes as an anxiety disorder aren’t experiencing something qualitatively different. They’re simply undergoing a more intense version of the same thing.

There is a third approach to understanding mental illness: the sociological model. Proponents argue that psychological disorders aren’t illnesses at all. They’re a label used to stigmatize and control behaviour society deems objectionable — such as homosexuality, which featured in the DSM until 1980.

Our view is that psychological problems aren’t illusory. They are real expressions of distress, for which most people — understandably — want help. However there is variability in the validity of individual diagnoses. Therefore it is often wisest not to focus on particular diagnoses. Better instead to adopt a dimensional approach, and to concentrate on the key problems and day-to-day symptoms that lead people to seek assistance. To help us understand these problems, we can look at epidemiological information to see which experiences occur together, and therefore may share common causes. Psychologists call this a data-driven approach.

We can also be guided by our knowledge of how the brain works. For example, basic emotions such as fear or unhappiness are powered by relatively distinct circuits in the brain. So we can understand certain psychological problems as what follow when these emotional circuits don’t function properly. We can match up the emotion and the problem: sadness and depression, fear and anxiety disorders, for example. This is what we might call a theory-driven approach, though given the complexity of brain activity it may – at least at present — be a little optimistic.

Importantly, even such a psychological, evidence-based approach doesn’t get around the need to classify problems. Mental health professionals must still make decisions about how to label the problems people describe to them. Without some kind of classificatory system, we can’t communicate, research, and evaluate treatments.

But the problems inherent in the current systems arguably constitute the greatest obstacle to that work. Given the extent of the burden on society and individuals alike, improving the scientific understanding of psychological disorders remains a priority. And that means DSM-5 certainly won’t be the last word on the classification of mental illness.

Daniel Freeman is a Professor of Clinical Psychology in the Psychiatry Department at the University of Oxford. Jason Freeman is a writer and editor. Their latest book is The Stressed Sex: Uncovering the Truth about Men, Women, and Mental Health (Oxford University Press).

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for views from Donald W. Black, Michael A. Taylor, and Joel Paris. Read yesterday’s post “DSM-5 will be the last” by Edward Shorter.

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In assessing DSM-5, the fog of battle has covered the field. To go by media coverage, everything is wrong with the new DSM, from the way it classifies children with autism to its unremitting expansion of psychiatry into the reach of “normal.” What aspects should we really be concerned about?

Think of a bowl of spaghetti. There are the central swirls of spaghetti in the middle of the bowl and the strands of spaghetti hanging over the side. Most of the controversy has been about the strands dangling down, how we classify marginal disorders of various kinds. It’s not that people with these disorders, such as the hyperactive and the autistic, aren’t important, but they aren’t the meat and drink of psychiatry.

The problem that the DSM-5 doesn’t address lies at the center of the bowl. It concerns psychiatry’s main diagnoses, not its marginal outliers, and those main diagnoses are major depression, bipolar disorder, and schizophrenia. The new edition hasn’t really touched any of them; the way they were defined and classified, and the way they continue to be recognized, ignores major differences within each diagnosis.

Keep in mind how easy it has been to get funny-sounding new diagnoses into psychiatry. Some, such as bipolar disorder, come in as a result of fad. A German psychiatrist named Karl Leonhard created bipolar disorder in 1957 when he said that there are two kinds of depression, unipolar depression (no mania) and the depression that alternates with mania (later called, in DSM-3 in 1980, bipolar disorder). Leonhard’s European and American disciples — a small but influential band — saw to it that separating depressions by “polarity” was widely accepted. Yet there was no new science here; it was the whim of one man.

Some of the diagnoses at the heart of the bowl came in by fiat. Robert Spitzer, the architect of DSM-3, simply decided in 1980 to collapse psychiatry’s various depressions — which had been as diverse as chalk and cheese — into a single disorder: major depression. There were howls of protest, but, hey, the thing was already in print. Set in stone. Even though it makes no scientific sense to classify depressions on the basis of polarity, that’s what we have ended up doing.

Serious depression — or melancholia — remains serious depression whether an episode of mania complicates it or not. Sooner or later, many patients with serious depression will experience some manic features, without that changing their basic diagnosis.

Related to schizophrenia, psychosis (loss of contact with reality via hallucinations or delusions) certainly exists. And there are many forms of it: some come out of the blue, others begin insidiously and seem to grow out of the patient’s personality; some involve loss of brain tissue, others don’t; some end very badly, others stabilize at the ability to lead a more or less normal life: you may not become a neurosurgeon, but you get married, have kids, keep a job, the whole ball of wax. These are different diseases.

St. Elizabeth’s Hospital. Wall of room in Ward Retreat 1. Reproductions made by a patient with dementia praecox…Pictures symbolize events in patient’s past life and represent a mild state of mental regression. Undated, but likely early 20th century. Washington, DC. Selected by Kathleen.

Yet we now give all these forms of psychosis a single diagnosis: schizophrenia. That’s without a plural “s.” If you’ve got chronic psychosis you’ll be called schizophrenic, even though you may not have any symptoms in common with others who have that diagnosis. You may have quite different family (genetic) backgrounds; you may not have a common response to treatment; and you may not have a common course and outcome. Those are all the ways we delineate separate diseases and “schizophrenia” demonstrates none of those hallmarks. It’s an artifact that Emil Kraepelin, the great German disease classifier, inserted into the literature in the 1890s, calling it dementia praecox. So powerful was his concept — that all the different “subtypes” of schizophrenia went remorselessly downhill — that the term has survived the relentless scientific plucking that all other diagnoses in medicine continually experience.

But conceptual power is not the same thing as verification. There is no marker telling us that everybody with “schizophrenia” has the same disease. (There are, by the way, such markers for some other major diseases; I don’t have space to go into it here, but google “dexamethasone suppression test”.)

So, are there problems with DSM-5? Yes, but they aren’t the problems most critics pick at. Criticisms of DSM-5 seem to be rising in a crescendo, as though a gaggle of high-school teachers were called to assess the work of a very naughty schoolboy. The drafters of the current edition were mightily concerned with maintaining stability; they didn’t want to hack great changes into previous editions. So there is not a chance in the world they would have looked critically at these central problems.

But out there in the real world, there are growing numbers of nosological rebels, or skeptics about the DSM version of disease classification. They have mainly stayed off the airwaves up to now. But you can feel the dubiety rising. There probably will not be a DSM-6.

Edward Shorter is Jason A. Hannah Professor in the History of Medicine and Professor of Psychiatry in the Faculty of Medicine, University of Toronto. He is an internationally-recognized historian of psychiatry and the author of numerous books, including How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown,  A Historical Dictionary of Psychiatry and Before Prozac: The Troubled History of Mood Disorders in Psychiatry. Read his previous blog posts.

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for views from Daniel and Jason Freeman, Donald W. Black, Michael A. Taylor, and Joel Paris.

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Image credit: By Otis Historical Archives National Museum of Health and Medicine (originally posted to Flickr as Reeve37258). Creative commons license via Wikimedia Commons.

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In 1913, Allgemeine Psychopathologie (General Psychopathology) was published. A guide for young students, doctors and psychologists, it had been completed two years earlier by a 28-year-old German psychiatrist: Karl Jaspers. He aimed to overcome scientific reductionism and establish psychopathology as a new comprehensive science during a period of significant advances in neuroscience. The work had an immediate, dramatic impact and is now a classic in psychiatric literature. Moreover, he established psychopathology as a discipline in its own right — to carefully describe, define, differentiate, and bring order to the chaos of anomalous mental phenomena.The relevance of psychopathology for psychiatry is threefold: it is the common language that allows specialists, belonging to different schools, each one speaking its own jargon, to understand each other; it is the ground for diagnosis and classification in a field where all major conditions are not aetiologically defined disease entities, but exclusively clinically defined syndromes; it makes an indispensable contribution to understanding, a special kind of intelligibility based on the meanings and conditions of possibility of personal experiences.

Department of Psychosis Studies, Institute of Psychiatry, King’s College London and OASIS Team, South London and the Maudsley NHS Foundation Trust, London, UK. Used with permission.

Psychiatrists need both the personal cultivation and thorough scientific education that psychopathology provides. Its emphasis on human experience, meaningfulness, and valid and reliable methodology to approximate human subjectivity makes it the organon of the humanities in psychiatry, and perhaps in medicine in general. When evidence-based guidelines are still scarce (as is the case, for instance, with early psychoses), psychopathological formation seems to be an indispensable resource for the psychiatrist. For example, it provides the ability to feel an atmosphere and attune to situations that are not yet plainly and unambiguously defined. Moreover, Jaspers drew attention to the active role of the patient. As a self-interpreting agent engaged in a world, the patient interacts with his or her basic disorder and contributes to the shaping of the clinical syndromes.

Jaspers was also active in other fields, such as philosophy, which deeply influenced his work as a psychopathologist. General Psychopathology tried to bring the direct investigation and description of clinical phenomena as subjectively experienced by the patients into the field of clinical psychiatry. Specifically, it changed our understanding of psychosis and schizophrenia. Jaspers’ phenomenological analyses of the pre-delusional atmosphere are still considered an outstanding example of “what it is like” to be a person who is undergoing puzzling and ineffable experiential changes which pave the way to full-blown schizophrenic delusions.

Today, Jaspers work continues to reward and inform psychiatrists. His phenomenological method can help solve ongoing diagnostic concerns by improving the validity of present clinical phenotypes and his approach can be integrated with current neurobiological hypotheses. His person-centered approach in clinical practice is very useful to contemporary psychiatry. In fact, patients are seen as meaning-making, participating in their own healing as empowered agents, and their behaviors not necessarily pathological but potentially adaptive. One hundred years on, we’re still learning from Karl Jaspers.

Paolo Fusar-Poli, MD, PhD, RCPsych is Clinical Senior Lecturer at the Department of Psychosis Studies at the Institute of Psychiatry, London and consultant at the OASIS prodromal team, South London and the Maudsley Foundation NHS Trust. Giovanni Stanghellini, MD and Dr. Phil. honoris causa is full professor of Dynamic Psychology and Psychopathology at Chieti University (Italy) and Associate Professor at Diego Portales University in Santiago (Chile). Schizophrenia Bulletin has a special issue on the 100th anniversary of General Psychopathology.

Schizophrenia Bulletin seeks to review recent developments and empirically based hypotheses regarding the etiology and treatment of schizophrenia. They have published a special issue devoted to the centenary of its publication (1913-2013), as well as other publications including the volume One Century of Karl Jaspers General Psychopathology to be published by Oxford University Press.

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The new television show Hannibal resurrects Thomas Harris’s famous serial killer and offers a few new surprises bound to shock both newcomers and longtime fans of Dr. Lecter. So while you’re catching up on the latest incarnation of the series, why not brush up on criminology facts or learn something new about cannibalism?

CRIMINAL PROFILING

How does Will Graham get inside the minds of serial killers?

Criminal Law: The Essentials
By Sue Titus Reid
This brief text will introduce you to the main issues and developments within the field.

Crime Profiles: The Anatomy of Dangerous Persons, Places, and Situations
By Terance D. Miethe, Richard C. McCorkle and Shelley J. Listwan
Learn more about the motivation and design of criminal acts.

Forensic Psychology: A Very Short Introduction
By David Canter
A thorough overview of the field of forensic psychology including a chapter dedicated to how to track down a criminal.

CRIMINAL LAW AND JUSTICE

Jack Crawford’s FBI team doesn’t have the best record for bringing in criminals alive, but what can they expect when brought to justice?

Criminal Law: The Essentials
By Sue Titus Reid
This brief text will introduce you to the main issues and developments within the field.

Minds on Trial: Great Cases in Law and Psychology
By Charles Patrick Ewing and Joseph T. McCann
A behind-the-scenes look into high profile cases with an emphasis on the testimonies of mental health professionals.

Criminal Law
By Sue Titus Reid
A broader overview of criminal law and justice through a modified case by case approach.

The Oxford Handbook of Crime and Criminal Justice
Edited by Michael Tonry
A guide to the American criminal justice system and essential to learn what happens next to the killers caught on the show.

Criminal Law
By Nicola Padfield
Review this concise volume on criminal law before the next big case.

PSYCHIATRY

Do you need to stay ahead of Dr. Lecter’s mind games with the latest developments in psychiatry?

Psychiatry: A Very Short Introduction
By Tom Burns
Test your knowledge on this field and see if you can keep up with Dr. Lecter.

Psychiatry’s contract with society: Concepts, controversies, and consequences
Edited by Dinesh Bhugra, Amit Malik and George Ikkos
Read this to get a better handle on the complicated relationship between doctor and patient (luckily not as complicated as Graham and Lecter’s will be).

SERIAL KILLERS

Where did Thomas Harris get his inspiration from?

Gangsters, Swindlers, Killers, and Thieves: The Lives and Crimes of Fifty American Villains
Edited by Lawrence Block
Learn about the real villains that could have been the inspiration behind some of the characters on the show.

The Oxford Companion to Crime and Mystery Writing
Edited by Rosemary Herbert
Review the entry on serial killers and mass murderers by Marion Swan to see how real life killers inspire our writers.

ANTHROPOPHAGY

How does human flesh taste?

The Man-Eating Myth: Anthropology and Anthropophagy
By William Arens
No book list on Hannibal Lecter would be complete without a few reference books on cannibalism.

The Oxford Companion to the Body
Edited by Colin Blakemore and Sheila Jennett
The entry on cannibalism by W. Arens provides a historical perspective on the anthropophagic nature of ‘others’.

Now that you’re prepared, use your newfound knowledge to solve the next case before Will does!

Kimberly Hernandez is a social media intern at Oxford University Press.

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Image credit: All images from the Hannibal television series copyright NBC. Used for purposes of illustration.

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By Tom Burns

National Mental Health week in May this year will see the launch of the eagerly anticipated DSM-5. This is the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual which defines all psychiatric diagnoses and is often referred to as ‘the psychiatrists’ bible’. How can something so dry and dull sounding as a classificatory manual generate such fevered excitement? Indeed how did the DSM compete for space in a short book such as the VSI to Psychiatry? Why does it take its place alongside acknowledged classics like Sigmund Freud’s Interpretation of Dreams, or RD Laing’s The Divided Self? The answer is that psychiatry is a practice that is highly sensitive to cultural and social pressures and the origins of the DSM-III, published in 1980, reflected a crisis in psychiatry’s self confidence and is a classic case of unintended consequences.

American psychiatry (which had been dominated by psychoanalysts from about 1940 to 1970) had its prestige seriously dented in the early 1970s. Two major international studies had indicated that they tended to dramatically over-diagnose schizophrenia compared to other developed nations. To make matters worse Rosenham’s famous study ‘being sane in insane places’ was published in 1973. Rosenham got eight volunteers to go to different emergency rooms and say that they were hearing voices that said ‘empty’, ‘hollow’, or ‘thud’ but otherwise to behave absolutely normally. All were admitted to hospital and kept there for several weeks, all were diagnosed with schizophrenia and none had their diagnosis questioned. Clearly this was dire, something had to be done.

DSM-III was the response, a totally new approach to diagnosis. Instead of making a diagnosis by recognising an overall pattern of the illness DSM-III introduced ‘criterion based diagnosis’. So to be diagnosed with a disorder, say depression, the psychiatrist had to identify a core symptom (criterion) of lowered mood for at least two weeks and then four more symptoms (e.g. disturbed sleep, reduced appetite, poor concentration or feelings of worthlessness) out of a list of eight. If you ‘score’ on enough symptoms you have the disorder, if not you don’t. This approach emphasises reliability; the symptoms are simply defined and explained so most doctors will agree on them. It leaves little scope for an overall judgment or deciding on the ‘feel’ of the patient’s presentation. Improving reliability and reducing the variation between different psychiatrists with sharper definitions was meant to reduce the loose over-diagnosis that had plagued US psychiatry up till then. It also should improve the reliability of the drug trials that were coming into prominence.

One should be careful what one hopes for. While the DSM criterion based system has undoubtedly made diagnosis more consistent, it has certainly not made it tighter. As we approach DSM-5 the expansion in this classification is simply staggering. DSM-I in 1952 had 130 pages and 106 diagnoses and has ballooned to DSM-IV in 1994 with 886 pages and 297 diagnoses. The number of individuals who are diagnosed with psychiatric disorders is at an all time high. There is a growing recognition that the DSM system has lead to a medicalisation of everyday life; far too many people with transitory sadness find themselves classified as depressed and prescribed antidepressants. Anxiety disorders such as PTSD and Social Phobia are all too easy to define and hence diagnose, but can they really be as widespread as current practice suggests? Most patients now end up with more than one diagnosis. Even the psychopharmacologists who agitated for DSM-III are now concerned that diagnoses are cast so widely that they undermine, rather than guarantee their trials.

The fact that one can define something and agree on the definition does not make it either real or important. For example, there was good agreement four centuries ago on how to recognise a witch, but that does not mean that these poor women were witches. Similarly having a definition for ‘Oppositional Defiant Disorder’ in adolescents who ‘often argue with adults’ does not make it a psychiatric disorder (any more than nicotine or caffeine dependency which are, believe it or not, listed in there).

Of course we should not be too dismissive about the progress that has been made in reliability and consistency. Psychiatric practice is vastly safer, more predictable and evidence based than ever before. We can hope that DSM-5 will transcend its committee structure and weed out earlier mistakes and sharpen up and refine the range of diagnoses, perhaps deleting those that are hardly ever used. It will certainly not be dull. Since its origins two hundred years ago psychiatry has never been without its controversies and disputes and all the signs are that this is likely to continue.

Tom Burns is Professor of Social Psychiatry at Oxford University and author of Psychiatry: A Very Short Introduction. He has worked as a psychiatrist in Scotland, Sweden, and London before moving to Oxford. He trained as a group analyst and worked as a full time NHS consultant for 10 years before becoming an academic. His research is focused on interpersonal relationships in psychiatry – increasingly relationships with health care staff and the best forms of care for patients with severe illnesses such as psychoses. He has authored over 200 scientific papers and chapters and is the author or co-author of five books. He was awarded a CBE for his services to mental health in 2006.

The Very Short Introductions (VSI) series combines a small format with authoritative analysis and big ideas for hundreds of topic areas. Written by our expert authors, these books can change the way you think about the things that interest you and are the perfect introduction to subjects you previously knew nothing about. Grow your knowledge with OUPblog and the VSI series every Friday and like Very Short Introductions on Facebook.

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Below, you can listen to Michael Trimble talk about the topics raised in his book Why Humans Like to Cry: Tragedy, Evolution, and the Brain. This podcast is recorded by the Oxfordshire Branch of the British Science Association who produce regular Oxford SciBar podcasts.

Listen to podcast:

[See post to listen to audio]

Or you can download it directly from Oxford SciBar podcasts.

Michael Trimble is Emeritus Professor of Behavioral Neurology at the Institute of Neurology, Queen Square, London. He is the author of Why Humans Like to Cry: Tragedy, Evolution, and the Brain and The Soul in the Brain: The Cerebral Basis of Language, Art, and Belief. He received a lifetime achievement award from the International Neuropsychiatry Association.

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On 24 April 1993, the city of London was brought to a standstill. A massive terrorist bomb exploded at the NatWest tower, killing one person and injuring at least 40 more. The truck bomb, planted by the Irish Republican Army (IRA) was designed to strike at the financial heartland of London, and it succeeded. In addition to the human casualties, what has since become known as the Bishopsgate bomb caused $1 billion in financial damages.

Twenty years later, the IRA is no more. Its members have laid down their arms and its leadership committed to a hard-fought peace process that has since brought stability and prosperity to a region of the world that has suffered four decades of terrorism. Perhaps the most visible signal of that progress came with the official visit of Queen Elizabeth II to the Republic of Ireland in 2011.

In a week in which terrorism came to the streets of Boston and was foiled in Canada, the past several years has seen the slow rise of terrorist activity on the streets of Northern Ireland.

The problems in Northern Ireland are mostly over. However, despite the extraordinary progress made via a hard fought peace process, the legacy of Northern Ireland’s Troubles is still deeply felt. Many people remain disaffected, disillusioned, and impervious to the prosperity brought by the stability of the peace process. Sectarian tensions occasionally bubble to the surface, and communities remain deeply divided with polarized identities. Visitors to Northern Ireland today will see a great change from the region’s darker days, but visitors will also see even greater signs of attempts to keep those communities separate via the increase in intimidating ‘peace walls’ (large structures that keep those divisions alive and visible). Given how deeply affected Northern Ireland has been from the Troubles, inter-community tensions will understandably take generations to fully heal, and that road will not ever be an easy one. But there are those who would quickly see that healing process stopped in its tracks.

Though the Irish Republican Army is no more, several small groups have split away from the ‘mainstream’ Republican movement, shunning the peace process and condemning the IRA leadership for compromising on the core ideals of traditional Irish Republicanism – to gain a United Ireland. The result has been a prolonged attempt at developing and sustaining campaign of low-level terrorism, characterized by intermittent though influential and impactful attacks.

These groups have many names. Known collectively as “dissident Republicans,” they comprise several small militant splinter groups. The “Real IRA” and the “Continuity IRA” are probably the most well known of these, though both of these entities have given rise to what my colleague Dr. John Morrison once called serial splintering, spawning several further sub-groups. They operate both in Northern Ireland and in the Republic of Ireland. What unites them is their hatred for the Sinn Fein leadership, their rejection of the authority of the Police Service of Northern Ireland, and their equally abject rejection of the various peace agreements that emerged in recent years. The differences between the various dissident factions will seem inconsequential to onlookers, but carry immense significance to respective followers. The various groups are as divided by personalities, jealousies, and petty rivalries as they are divided along geographical, ideological, and strategic lines.

Aside from a clichéd call to “uniting Ireland,” what they want is never entirely clear because their aims are often lofty and obscure when you examine the respective groups’ ideological statements. On a day-to-day basis, what drives and sustains them is their utter hatred for Sinn Fein and the IRA leadership for what the dissidents feel is a ‘sell-out’. The dissidents view the peace process as an abject failure, a compromise that hasn’t delivered the Irish Republican fantasy of a 32-county Irish Republic. They want a united Ireland, but won’t engage in democratic means of achieving that. They take great psychological solace from their ‘outsider’ status, with one faction reveling in what they call a state of ‘noble isolation’.

There are some important tactical differences between the various factions, but in a nutshell, they engage in low-level terrorist tactics in an attempt to grab attention. They’re aware of their ability to carefully choreograph media attention and they commit semi-regular acts aimed at disruption (e.g. by leaving a pipe-bomb in a public place) and targeted killings. They have killed prison officers and police officers, and have increasingly threatened members of Sinn Fein. Though their ranks include former senior members of the IRA, they have attempted to recruit adolescents and young children in recent years. They are adept at social media. They engage in public displays of strength, marching and protesting, and in intelligence gathering on future potential targets. They are aware of the fact that they are heavily monitored by the security services but view this as a badge of honor, affirmation of their importance.

These dissidents are characterized by remaining a heterogeneous and divided cluster of small groups. There is always the danger, however, that a highly symbolic act of violence could serve to unify them in ways that will appear obvious only with hindsight. Entrepreneurial dissidents have made multiple attempts to form a coalition, but these have failed to gain much traction. There is a sense, however, that the forthcoming 100th anniversary of the 1916 Irish Republican rebellion may ultimately serve to focus the dissidents in ways we haven’t seen before. We should not rule out the possibility of a high profile, targeted attack in the next two years.

Nobody is overestimating the dissident Republican threat, but it would be very dangerous to underestimate them. They continue to recruit and train, and they are deeply embedded in crime, especially in the Republic of Ireland. A single successful attack (especially if the target is psychologically significant to them) could serve to unify their otherwise divided elements and re-energize their (albeit small) base of supporters. Their small size and lack of popular support should not be taken as a measure of their weakness. Instead it points to their unpredictability given their insensitivity to the broader community consensus that the dissidents are fighting a fantasy war that nobody wants. But unpredictability and insensitity to the broader public make for very dangerous conditions in the context of terrorist threat assessment. The current consensus is that the dissidents may well be infiltrated by police and intelligence agents given a fairly persistent track record of foiled and failed bomb plots in recent times. But they have often found inspiration from high visibility targeted attacks, and given that the 2016 anniversary may well be their last opportunity to prove relevant, it would be wise to keep a close eye on their efforts.

John Horgan is author of Divided We Stand: The Strategy and Psychology of Ireland’s Dissident Terrorists. He is Director of the International Center for the Study of Terrorism at the Pennsylvania State University, where he is also Associate Professor of Psychology. He is a member of the editorial boards of multiple journals, including Terrorism and Political Violence, Studies in Conflict and Terrorism, Journal of Investigative Psychology and Offender Profiling, Behavioral Science of Terrorism and Political Aggression, and Dynamics of Asymmetric Conflict. Dr. Horgan is a member of the Research Advisory Board of the FBI’s National Center for the Analysis of Violent Crime (NCAVC).

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Mike was a doctoral student profoundly appreciated and esteemed by faculty, peers, staff, and all who came in contact with him. As is typical in our community, Mike was already a successful mid-career professional. He worked in the tech world and brought his expertise to us. He didn’t have a background in research psychology, but in the last year of his doctoral program, his work was published on nine occasions. Nine publications during the last year of graduate school is an incredible feat for anyone. But the heart-wrenching part of the story is that in the last eight months of his doctoral program, Mike also learned he had life-threatening cancer to which he finally succumbed about a month after graduation.

Mike’s family kept a blog of his progress and not long after graduation we learned that the end had come. Some of us attended the funeral in person. One member of our community gave the eulogy—a very stirring story of their travels, work, and time spent together in the program. The funeral was even livecast on the web so those who couldn’t be there physically could attend virtually.

Mike’s virtual wake

In the midst of these events, several of us wanted to commune so we held what amounted to a kind of virtual wake—a video chat with people from all around the country talking about our shared loss and joy of having had Mike in our lives. Several of us wrote eulogies for Mike and shared them with each other online. In mine, I spoke about how my relationship with Mike flashed through my mind like a dream sequence. In it, I remembered Mike and I in various settings: walking on the beach planning research, touring the MIT Media Lab, attending a presentation at Harvard’s Berkman Center for Internet research, and talking on the phone or Skyping.

People often grapple with the question of what is “real” versus “unreal” in the realm of media and technology. As a media psychologist I study how media use influences our feelings, actions and thoughts, and use media every day to teach a doctoral program that uses a hybrid model of higher education. While we do meet face-to-face (F2F), more often we use other forms of communication to meet virtually.

My students and I text, call, video chat, email, and post in social networking groups.  We discuss research walking the beach, brainstorm together in a seminar, or hold intriguing debates via video chat. Our F2F meetings are what one colleague calls “intense bursts of togetherness.” They’re the kind of thing where you might spend a week in morning-through-night meetings, classes, and social gatherings.  These varied means of communication have a deep reality for us, and through these experiences we are bonded together in unique ways. Our community is a kind of exciting world-within-a-world where we study what we do and we do what we study.

But for now, I’m honored to tell part of Mike’s story, and in some way, Mike’s presence in our virtual community is a legacy of the powerful ways technology can bring us together.

Karen Dill-Shackleford is the author of How Fantasy Becomes Reality and the editor of the Oxford Handbook of Media Psychology. She has testified before the US Congress about media violence and about representations of race and gender in the media. 

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Journalists want to report the news not be the news. But in the case of Ann Curry, the former Today show co-host who was pushed into stepping down from the co-anchor slot last June, she has become the news. New York Times reporter Brian Stelter’s recent feature article about morning television and the toxic culture at NBC’s Today show provides more than enough information to conclude that Ann Curry was a target of workplace mobbing.

Whatever your personal opinions of Curry and her work, she was clearly mobbed out of her Today show job. Workplace mobbing is a process of humiliation and degradation of a targeted worker with the purpose of removing that worker from the workplace or at least from a particular unit of it. It is a dark side of organizational life, involves co-workers ganging up on the target, and includes management’s involvement through active participation in the mobbing or through failure to stop it once it becomes known to them. Mobbing in the workplace includes a characteristic course of events that were first described by Heinz Leymann, the psychiatrist who conceptualized the problem in the 1980s. Let’s look at what Stelter reports as having happened to Ann Curry through the framework of this pattern of events representative of workplace mobbing.

• Today was losing market share, critics were saying the show was stale and that there was no chemistry between the co-hosts Ann Curry and Matt Lauer. Understandably, management was concerned. Their solution, however, is a classic error of logical type. Blame an individual — in this case, Ann Curry — for what was obviously a much more systemic problem. (Precipitating event or situation)
• Once “the problem,” had been identified as Ann Curry, management’s next step, according to Stelter, was to mount a campaign to get rid of her and they even had a name for it, “Operation Bambi.” (Targeting of a worker for elimination and involvement of management or administration)
• Curry was subjected to a series of hostile, negative acts that by most people’s standards would be humiliating and hurtful. Stelter reports the making of a blooper reel that showed Curry’s worst on-air moments and blunders, the gathering of staff to watch a particular on-air gaffe and presumably to talk about it, the collection of boxes of Curry’s belongings in a closet as if she had already left, control room staff making fun of Curry’s clothing choices and “generally messing with her,” and the comparison of a yellow dress that she wore to Big Bird and photo shopping her head on to Big Bird’s image and then asking staff to vote on which one wore the yellow outfit best. (Unethical communication about the target and series of negative acts)
• Such negative acts, tailored to the particular work environment, are characteristic of workplace mobbing and serve several functions. They separate and exclude the target from the rest of the workplace, telegraph to other workers that the target is “damaged goods,” and encourage a general ganging up on the target. Once the target in a workplace mobbing has been cast as “other,” and as “less than” it’s much easier to further objectify that person and treat him or her callously. The negative acts can go on for months, as seems to be the case for Ann Curry, or even years as has been the case for others who have been mobbed in the workplace. It doesn’t take much imagination to appreciate the human toll of psychological and physical suffering that such ongoing hostility and abuse causes. (Isolation and exclusion of the target, more ganging up, and resulting escalation of mobbing)
• On 28 June 2012, Ann Curry emotionally announced her departure from the Today show. It was clear to anyone watching her announcement that she was in pain and that she was not happy about leaving. The mobbing of Ann Curry was entirely successful. She was now gone from the Today show. Stelter notes that the executive producer led a group of Curry’s co-workers in a toast to her departure at a nearby restaurant only hours after her announcement that she was stepping down. Such cheering and celebrating after a successful workplace mobbing is common and fairly predictable. (Elimination from the workplace)

For most people who are victims of workplace mobbing, an unfortunate and common workplace event, the aftermath is difficult at best and disabling at worst. Income is lost, health and retirement benefits can be lost, reputation is damaged, professional identity is compromised as is the victim’s career trajectory, family and friendship relationships are strained, and the lingering traumatic effects of the interpersonal abuse and social exclusion at the heart of workplace mobbing can persist for a very long time. It is no surprise at all that Stelter reports Ann Curry as having described her experience as “professional torture.” Heinz Leymann called workplace mobbing “psychological terrorism.”

Ann Curry’s multi-million dollar salary may make the financial side of being a victim of workplace mobbing a lot easier for her than it is for most victims. I would assume, though, that her salary doesn’t ease the psychological and emotional pain she has had to endure and that is most likely her legacy from having been mobbed. While Ann Curry may not like the position of being the news, the story of how she was a victim of workplace mobbing is important. The stories of many others who have been victims of workplace mobbing but who are not public figures might more fully be understood through hers.

Maureen Duffy is a family therapist, educator, and consultant about workplace and school issues, including mobbing and bullying, and is the co-author of Mobbing: Causes, Consequences, and Solutions and the forthcoming book, Overcoming Mobbing: A Recovery Guide for Workplace Aggression and Bullying. Read her previous blog posts “Seven ways schools and parents can mishandle reports of bullying” and “Excluded, suspended, required to withdraw.”

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Immediately after two bombs rocked Boston Marathon bystanders and runners, medical volunteers, Medical Reserve Corp members, and law enforcement were seen running to aid victims. For those who suffered trauma, it is likely that these heroic and timely interventions saved lives and improved outcomes. Regrettably and realistically, most future terrorist targets will not have the benefit of a relatively large cadre of trained first aid responders who are standing by and ready to treat heat stroke and other running-related maladies. By all reports, Boston had taken adequate steps to meet the potential medical needs of the runners and to protect the public from a terrorist attack. Yet even with a pre-event sweep of the area for explosive devises and extra police presence on site, two explosions occurred.

Boston Marathon explosions. 16 April 2013. Photo by Aaron Tang. Creative Commons License. flickr.com/photos/hahatango/

It is well recognized that soft targets, such as races, outdoor concerts, and shopping malls, are much easier to attack than hard targets with a strong security presence, like airports and athletic events held in stadiums. Events or locales that are frequented by the public and not subject to security checks will always be at high risk. Given the likelihood of an increased volume of natural disasters, technological catastrophes, pandemics, and terrorist events it is time to reconsider our existing first aid training model. At present, non-profit agencies like the American Red Cross and the American Heart Association, routinely offer first aid training to first responders as well as to the general public. However, this approach is no longer enough. A key challenge is the small number of people who are trained to provide both medical and psychological intervention. Further compounding this dilemma is the shortage of trained first responders who can be deployed to assist survivors and communities in rural areas or in communities with limited resources. As a nation we would be better served by using an effective training model commonly implemented in public schools by local fire departments.

Across America, many fire departments provide fire safety training to upper grades in elementary schools. Students are taught basic fire safety that includes, but is not limited to verifying the presence of home smoke alarms, having an escape route, and knowing the steps to take should a fire occur. Because of this approach, we have been largely successful in creating a culture that recognizes and values fire preparedness and safety. Incorporating fire safety training into school curriculum makes sense and is easily justified because relative to other types of disasters, fire emergencies are high base-rate events.

Today most buildings are inspected by fire marshals and equipped with a variety of fire alarms, extinguishers, and sprinklers. Additionally, most communities have dedicated personnel, fire stations, and vehicles that are highly visible and ready to respond to emergencies. In marked contrast, it is likely that few people know the location of their local emergency operation center or disaster shelter, have an emergency plan, or own an adequately stocked to-go kit. Given the challenges in preparing for high impact but low base-rate disasters, it is imperative that we expand the model currently in place for fire safety to include first aid training.

A first aid training program should be incorporated into upper middle school curriculum with yearly recertification required. The proposed model should not be solely limited to medical first aid, but should also include training in psychological and mental health first aid. A basic premise of first aid is that appropriate, early intervention can mitigate functional impairment and reduce the potential for more serious and enduring health problems that require formal treatment. A comprehensive first aid program is critical as most natural and human-caused disasters result in a high incidence of psychological and not physical casualties. Just as medical first aid may save lives or offset more serious medical complications, psychological first aid has the potential to mitigate serious mental health consequences and build resilience. Moreover, delivery of psychological first aid in tandem with medical intervention would not only be feasible but highly desirable.

The proposed first aid training approach is appropriate for many types of crises, suitable for training both professional and laypeople, applicable to a broad range of disaster events, and incorporates evidence informed practices. We believe that adoption of the first aid training model described above would represent significant progress in fulfilling a key element of the Pandemic and All-Hazards Preparedness Act of 2006 mandate (PL 109-417). By training all students to use first aid techniques we take an important and much needed step toward preparing our citizenry to respond to all types of disasters.

Lisa Brown and Bruce Bongar are editors of Psychology of Terrorism with Larry E. Beutler, James N. Breckenridge and Philip G. Zimbardo. Lisa M. Brown, Ph.D. is a tenured, Associate Professor in the School of Aging Studies, College of Behavioral and Community Sciences, University of South Florida. Dr. Brown’s clinical and research focus is on aging, health, vulnerable populations, disasters, and long-term care. Since 2004, Dr. Brown has studied the short- and long-term psychosocial reactions and consequences of natural and human-caused disasters. In addition to her scholarly activities, she is also a Medical Reserve Corp volunteer. Bruce Bongar, Ph.D., ABPP, FAPM is the Calvin Professor of Psychology at the Pacific Graduate School of Psychology at Palo Alto University, and Consulting Professor in the Department of Psychiatry and the Behavioral Sciences at Stanford University School of Medicine. Dr. Bongar’s main research focus is on suicidal behavior, clinical emergencies, psychology of terrorism, and suicide terrorism.

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Albert Hofmann was one of the most important scientists of our time, who through his famous discovery of LSD, crossed the bridge from the world of science into the spiritual realm, transforming social and political culture in his wake. He was both rationalist and mystic, chemist and visionary, and in this duality we find his true spirit.

In boyhood, he had experienced inexplicable, spontaneous transfigurations of nature while walking in the woods, which spurred him to investigate the nature of matter through chemistry. While researching ergot and its potential impact on blood circulation, he accidentally discovered a chemical key that unlocked a pathway to a profoundly altered state of consciousness, offering the potential for great insights into the workings of the mind and the cosmos.

After experiencing its power and its dangers first-hand on his infamous bicycle ride (70 years ago today, on 19 April 1943), Hofmann understood that LSD, if used correctly and with care, could be a vital tool for investigating human consciousness. In later research, he realised that the molecule had virtually the same chemical structure as those in plants used as sacraments for thousands of years by indigenous cultures around the world. He was also the first chemist to isolate the psychoactive compounds of psilocybin and psilocine, found in ‘magic’ mushrooms and the closely connected morning-glory seeds.

Following its discovery, LSD was acclaimed as a wonder-drug in psychiatry, speeding-up and deepening the healing process by accelerating access to psychological trauma. Between 1943 and 1970, it generated almost 10,000 scientific publications, leading to its description as ‘the most intensively researched pharmacological substance ever’.

It also had a broader and more profound effect on how science viewed the mind, changing the dominant view of mental illness from the psychoanalytical model to one understood by brain-chemistry and the role of neurotransmitters. The LSD-experience resembled looking through a microscope and becoming aware of a different reality — a manifest, mystical totality, normally filtered out and hidden from view.

Hofmann realised that a substance with such profound effects on perception was likely to arouse interest beyond the medical field — though he never expected it to find worldwide popularity as a recreational drug. But ‘the more its use as an inebriant was disseminated… the more LSD became a problem child’. These negative developments were not to Albert Hofmann’s liking. He was amazed that LSD had been adopted as the drug of choice by the mass counterculture, but once the genie was out of the bottle, the world could never be the same again.

Albert Hofmann during a discussion “about beauty” at the Zürich Helmhaus. Photo by Stefan Pangritz, Lörrach. Creative Commons License.

Harvard-Professor-turned-Pied-Piper Timothy Leary emerged as a messianic guru. The mass consumption of psychedelics that Leary advocated led to LSD’s prohibition in 1967, to the War on Drugs, and to the complete shutdown of all therapeutic use and scientific research involving the substance.

The legacy of LSD is as controversial as it is profound, and its effects on science, technology, politics, art, and music cannot be overestimated. Many creative pioneers of the era claim to have made their breakthroughs either under the influence of LSD, or as a result of insights gained from it. The IT revolution that grew into Silicon Valley is a prime example of this.

In recent years, despite huge obstacles, the experimental use of LSD is, very cautiously, beginning again. Earlier this year, the Beckley Foundation received the first ever permissions for a brain-imaging study of the effects of LSD on human participants, an undertaking that I promised Albert Hofmann I would carry out.

With other psychedelics, the renaissance in experimentation is well and truly underway. Projects have investigated the neural basis of the effects of psilocybin and MDMA, while other research in the USA and elsewhere has made vital first steps into uncovering the clinical efficacy of these drugs — for example, MDMA’s success as an aid to psychotherapy in treating Post Traumatic Stress Disorder.

The Medical Research Council in the UK recently gave a £550,000 grant to investigate the efficacy of psilocybin in treating depression, marking the first time (as far as we are aware) that a government body has funded psychedelic research. There is thus reason for renewed optimism that, as Albert Hofmann hoped, if people could learn to use LSD more wisely, once again ‘this problem child would become a wonder child’.

Amanda Feilding is the Director of the Beckley Foundation, which studies the effects of psychoactive substances and promotes drug policy reform. She is the co-editor of LSD: My problem child by Albert Hoffman with ethnobotanist Jonathan Ott. The Psychedelic Science Conference 2013 will be held in California 18-23 April.

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On the 14^th of April, single Koreans will signal their singleness by wearing, eating, and experiencing “black” as a statement on the nature of being single.

From the perspective of mating intelligence, following mating-relevant customs that are specific to one’s culture is crucial in mating. Knowing the rules and showing others that you can play by these rules is a signal to others that you have your stuff together. On this day in South Korea the rules are as follows: if you’re single, you’re to publicly display this fact by eating, wearing, and experiencing black. Doing so shows that you know what the rules are and that you’re willing and able to play by them. Ultimately, such a signal is attractive to potential mates and such signaling may, ironically, be a key to attracting mates on Black Day.

A typical Black Day sadness bowl. Photo by egg™, Creative Commons License, via Wikimedia Commons.

From an evolutionary perspective, the nature of pairbonding is ultimately rooted in the costs associated with parenting that typify our species. According to Trivers’ parental investment theory, in species that have relatively altricial (helpless at birth) offspring, mating systems favor pairbonding to help bring multiple adult helpers to assist with the raising of young. And humans fit this model in spades. Pair-bonding, a form of reciprocal attachment, is observed among humans in romantic relationships across cultures and social structures. Although the norms found vary quite a bit across cultures, most cultures have some sort of institutionalized guidelines on pair-bonding (often overlaying with marriage in an extended pair-bond situation).

Buster Keaton and his wife, pair-bonding. Chicago Historical Society.

Many modern cultures now experience (and socially accept) higher rates of single parenting and individuals marrying later in life. However, evolutionarily speaking, being shut out of the mating game, or in the case of a female, waiting too long, is a dead end for reproductive success. As such, it makes sense that cultural norms would address the issue of being single (as cultural norms often pertain to evolutionarily important issues such as mating, parenting, how to treat others, and so forth). At the very core of the matter is what many consider to be the ideal: reciprocal attachment, or pair-bonding, and the stigma associated with a lack thereof. Thus, it may be possible to infer that cultural norms aimed at recognizing “singleness” actually help develop signals that assist individuals in engaging in mate-seeking strategies.

Black Day seems to be a culturally specific way to acknowledge this issue of being single. Not only to support those who are unattached, but also to call attention to “singleness,” which ultimately can help people plan for mating-relevant aspects of their future. Outwardly, the process of commiserating with other singles may appear to be a way of establishing a similar in-group experience as those who have found themselves in relationships. But it also has the possibility of being more. Events designed by and for singles may help these singles “signal” to other unattached individuals that they are ready, willing, and able to invest in pair-bonding behavior.

Like the peacock that displays his plumage for potential mates despite the risk of being quickly eaten by predators, single people unite during holidays such as Black Day to display their wares in hopes of finding a kindred soul. By outwardly participating in the rituals of the celebration, they potentially place themselves at risk of being scorned by the elite group of those who are attached, but the potential to reap the evolutionary benefits may outweigh the costs. Effectively navigating such decisions is a crucial part of human mating intelligence.

Willing to be eaten for love. Peacock photo by Louise Docker (aussiegall), Creative Commons License, via Wikimedia Commons

In South Korea, donning all black clothing and going out to share the traditional comfort-food meal of noodles and black bean sauce could provide just the opportunity for single people to connect with others in the same position. These culturally specific customs provide an occasion for individuals to seek out and evaluate potential mates by engaging in a variety of evolutionarily based mating displays. In fact, in the absence of issues of mate-guarding, and potentially reduced intrasexual competition, singles on Black Day may have an even better chance at spending the next 14 April on the other side of the relationship fence.

Jessica Fell Williams is a Masters Student in Psychology at SUNY New Paltz and Strength Coach at Gunx CrossFit. Glenn Geher is the Director of Evolutionary Studies at SUNY New Paltz and Chair of Psychology; he’s also the co-author (with Scott Barry Kaufman) of Mating Intelligence Unleashed: The Role of the Mind in Sex, Dating, and Love.

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The field of autism is riddled by several unsolved mysteries.

One concerns the rate of children who suffer from autism spectrum disorders (ASDs). A study released last year by the CDC’s Autism and Developmental Disabilities Monitoring Network used school behavioral assessments and clinical reports of children who were 8 years old in 2008 and applied a standard checklist of criteria for diagnosis. This study said that the likelihood of ASD was 1 in 88 in the United States.  A new study published this March (2013), was based on a 2011-2012 phone survey of parents with children aged 6 to 17 years of age and identified as many as 1 in 50 of those children with ASD. The new study noted that the increase may have included children with milder cases and may have been the result of diagnoses of children with previously unrecognized ASD. However, whatever the actual number, these are shocking figures.

A second unsolved problem in the field of autism is how to identify infants who will later be diagnosed with autistic features. Since there is evidence that targeted educational therapies started at a very early age can make a difference in later social development, a number of current clinical studies are focused on the challenge of early infant identification. The importance of this problem can not be overstated because medical therapies, possibly even curable ones, are already in the pipeline for certain individual disease entities with autistic features.

A third deeply troubling unsolved question is in regard to the etiology of autistic behavior. In the 1970s, the earliest reliable epidemiological studies showed about 2 in every 1000 children were diagnosed with autism or an autistic-like impairment compared to today’s dramatically different prevalence figures noted above. Are these increases solely due to more accurate and complete diagnostic acumen or are one or more other factors also involved? There are many studies examining this unresolved controversial problem.

But one important mystery about autism has been solved. The belief that autism was a single disease, as originally described by Kanner, is known to be incorrect. The first clues came from biochemistry where blood results were so variant that they could not be used to predict a result in a child diagnosed with autism.  For example, blood studies of the neurotransmitter, serotonin, was found to be elevated in some children, within normal ranges in others or below normal in a third group. Recently with the advent of genetic research, an explosion of new information is now available and has established that autism is, in fact, many different diseases. A constantly increasing number of distinct individually rare genetic and genomic causes of ASD are being reported. The evidence is building that the genetic architecture of ASD resembles that of intellectual disability with its hundreds of genetic and genomic disorders involved, each accounting for a very small fraction of cases.

The mutations found in these children with ASDs fall into two groups: those with family members who also have the mutations and those with that occur de novo. Regarding familial studies, studies of identical twins have shown a markedly increased (but not 100%) co-occurrence  of autistic features in such twins compared to fraternal twins. And there is evidence of autism risk across generations. For example in a recent Swedish study, a statistically significant association was found between advanced parental age at the time of the birth of the parent and the risk of autism in the grandchildren. Regarding de novo studies, the recent whole-exome sequencing studies in populations of autistic children have showed an increased rate of these rare de novo mutations.

Just as we know that intellectual disability is a series of neurodevelopmental syndromes due to chromosomal imbalances, submicroscopic deletions and duplications called copy number variants (CVAs), classic genetic mutations, infectious, endocrine and toxic etiologies — so is similar information now being published and accumulated in the literature about children with ASDs. There are virtually no studies on intellectual disability as one single disease entity any more. Although a majority of children with autism still remain without a specific diagnosis at this time in medical history, each month the number of idiopathic cases decreases. Imaging, a variety of genomic techniques and rodent models are helping us progress in our understanding of how autistic features occur. Rather than look at autism as one disease, a more sophisticated subgrouping of patients with ASD in research studies is now needed. We also need to slowly and painstakingly determine the etiology in each beautiful child, one by one, who presents with autistic features.

Mary Coleman MD is Medical Director of the Foundation for Autism Research Inc. She is the author of 130 papers and 11 books, including six on autism. Her latest book is The Autisms, Fourth Edition co-authored with Christopher Gillberg MD. Read her previous blog posts “Can a child with autism recover?” and “Is there an epidemic of autism?”.

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Image credit: A hand writing the word Autism on a chalkboard under colorful puzzle piece drawings. Image by sdominick, iStockphoto.

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Many parents and professionals are debating the American Psychiatric Association (APA) approved DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) revised diagnosis of autism. DSM-5 is expected to be available for purchase by the time of the APA Annual Meeting in May 2013.

Autism Spectrum Disorder (ASD), the revised diagnostic category, is a developmental neurobiological disorder, characterized by severe and pervasive impairments in reciprocal social interaction skills and communication skills (verbal and nonverbal), and by restricted, repetitive, and stereotyped behavior, interests, and activities. The current DSM-IV-TR describes Pervasive Developmental Disorder (PDD) as the diagnostic umbrella, with five subtypes. With the upcoming changes in DSM-5, the separate diagnostic classifications under PDD will be subsumed under one category Autism Spectrum Disorder (ASD). This puts autistic disorder, Asperger’s disorder, pervasive developmental disorder not otherwise specified, and childhood disintegrative disorder under ASD. The new ASD diagnostic category will include specifiers for severity and verbal abilities, and also include associated features such as known genetic disorders, epilepsy, and intellectual disability.

The new ASD diagnostic category will also combine the current three domains (social, communication, and behaviors) into two domains (social and communication deficits, and fixated interests and repetitive behaviors), based upon the belief that deficits in communication and social behaviors are inseparable. Much debate has been triggered by these APA approved changes. One concern raised is whether the new ASD label will exclude individuals currently diagnosed with autism or PDD. A second issue highlighted is the fear of loss of school placement and funding if the new ASD label excludes a child previously diagnosed with autism or PDD. A third objection voiced is the loss of identity of individuals diagnosed with Asperger’s Disorder into the broader ASD category. Researchers have defended the new categorization as an improvement in evidence-based criteria which will not negatively impact individuals with ASD.

Time will tell if the new ASD diagnostic category is an improvement in the field of autism, and if researchers show the benefit rather than detriment.

Martin J. Lubetsky, MD is Associate Professor of Psychiatry at the University of Pittsburgh School of Medicine, and the Chief of Child and Adolescent Psychiatry Services and Center for Autism and Developmental Disorders at Western Psychiatric Institute and Clinic of UPMC, and Chief of Behavioral Health at Children’s Hospital of Pittsburgh of UPMC. Dr. Lubetsky is a past recipient of the Grandin Award from the Advisory Board On Autism and Related Disorders (ABOARD). He is co-editor and co-author of Autism Spectrum Disorder.

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(1) Be aware that people with autism can usually understand more than they can express.

Autism doesn’t change the fact that everyone understands more than they can express. When we learn a new language, we can understand what someone is saying long before we can create sentences that demonstrate the depth of our knowledge. Babies can understand a great deal of language before they begin to speak their first words.

People with autism often communicate differently to express what they know and want to share. Some will write thoughts on paper, or draw a picture demonstrating intent. They may use sign language, or a stack of picture cards to convey wants and needs. Many people with autism use shorter sentences with simplified language. This does not mean they are not thinking and comprehending full sentences with higher-level vocabulary. Being willing to communicate in a different way will allow you to be aware that communication comes in many forms. Autism Community provides resources and strategies to assist with communication and children with autism.

(2) Be aware that people with autism can be sensitive.

We learn our senses in first or second grade and can name ‘the five senses’ as tasting, touching, hearing, smelling, and seeing. In addition, we have two other senses that can let us know whether we are upside down or right side up and whether we are being squeezed or free to move. Almost all persons with autism have sensitivities that include one or more of these seven areas. In fact, most people in general have sensitivities in these areas as well. The difference is in the severity of the sensitivities. Some people with autism are hypersensitive to some of these areas and some are hyposensitive to some areas. Every person with autism is different; in fact, every person is different (whether they have autism or not)!

When near someone with autism, pay close attention to the way she reacts to sounds and lights, or how close she wants to stand to others. An awareness of these sensitivities can make a big difference in the way a person with autism engages in social events and activities. The Sensory World of Autism shows the sensory perspective of children with autism spectrum disorder that also struggle with sensory challenges.

(3) Be aware that people with autism think differently.

Someone who has autism often thinks differently. Different is not better or less than — it is just different. Someone with autism may need a longer period of time to process a question or statement. It is also common for a person with autism to think visually (or in pictures) and to be able to express thoughts easier using visual cues or images. An awareness of cognitive differences can go a long way toward being aware of the individual personhood of those with autism.

(4) Be aware that people with autism probably have a specific interest or topic that may help with communication.

Many of us have a specific area of interest that we enjoy discussing. Persons with autism often have an area of interest as well. It can be difficult for someone with autism to stop talking about or communicating this interest; therefore, it can be a great way to get to know someone by asking about this topic.

This awareness can be a terrific ‘ice breaker’ or a way to deepen a relationship with someone who has autism. The Indiana Resource Center for Autism at Indiana University offers unique strategies for parents and teachers in regarding to teaching and motivating children with autism.

(5) Be aware that people with autism tend to focus on the trees rather than the forest.

It can be difficult for someone with autism to think critically without focusing on minute details. If the discussion is about clothing, it may be necessary for the person with autism to discuss the stitching style used by the designer or seamstress. This often leads to the area of interest a person with autism may have, and is part of the cognitive patterning unique, yet familiar, to him. Be aware that the repetition or consistent use of minutiae rather than broad thinking is part of cognitive processing for a person with autism.

(6) Be aware that a child (or adult) with autism may be having a moment in public that seems confusing to you.

Because of sensory, cognitive, communication, and social differences, people with autism (and/or their family members) may sometimes have moments in public that can appear to be very different than they are. Because some people do not understand the differences and challenges that surround a family living with autism, they sometimes offer comments they feel may be helpful, or worse, judging glances and verbal recriminations to a family already in the middle of a negative moment or meltdown.

Being aware of the frustrations and challenges inherent within a family, and remembering to walk a mile in their shoes before coming to a conclusion, can be an excellent start in developing an awareness of autism. Moreover, what family doesn’t have its moments?

(7) Be aware that people with autism may need help with social circumstances.

Social situations can be beyond awkward for someone who has autism. The combination of sensitivities, communication differences, and expectations others have can be overwhelming. Having a friend to help guide a person with autism through the event, or a set of cards with conversation starters, etc. can be very helpful.

Be aware of the possible confusion and uncomfortable feelings someone with autism can have when placed in a social situation. Planning ahead with the needs of the person in mind can lead to a successful and less stressful social encounter. Social stories can be used to help facilitate positive, appropriate social skills.

(8) Be aware that a family that includes a person with autism may be tired and stressed.

It can be exhausting to be part of a family that includes one or more persons with autism. The daily challenges can mount and become overwhelming. Knowing that families who have members with autism (or other challenges) are often under a great deal of stress is a first step toward an empathic view. Families may honestly be too tired to set up play dates, go out to eat, or meet at the park, because the planning and implementation of these seemingly ordinary events can be overshadowed by the demands of daily life (cognition, communication, sensitivities, social challenges).

Awareness of and compassion for the needs of a family is sometimes demonstrated by planning events that take the needs of the entire family into consideration, or even, letting a family ‘off the hook’ knowing they may be exhausted from the demands of their daily lives. Support groups such as the Autism Society of America and Autism Speaks can help families connect with other families to share their stories and obtain services.

(9) Be aware that a child with autism may have siblings that get less attention than they do.

Siblings of those with autism may sometimes feel ignored or set aside because the needs of a brother or sister with autism overshadow the needs of the sibling at times. Developing an awareness of the specific feelings a sibling may have, and responding to that sibling in a way that conveys understanding can make a big difference in the life of that child or adult. Sibshops is a national organization that assists and provides programming for siblings of children with disabilities.

(10) Be aware that a person with autism is a person and not a label.

Autism is a label. Cans, cars, clothing, and technology have labels. People are not labels. A person with autism is a person. Be aware at all times that labels define and limit — real understanding comes with knowing the individual and responding to her needs.

Alice M. Hammel and Ryan M. Hourigan are the authors of Teaching Music to Students with Special Needs: A Label-Free Approach and the forthcoming Teaching Music to Students with Autism. Alice Hammel teaches for James Madison and Virginia Commonwealth Universities, and has years of experience teaching instrumental and choral music. Ryan Hourigan is Assistant Professor of Music Education at Ball State University and a recipient of the Outstanding University Music Educator Award from the Indiana Music Educators Association. The companion website to Teaching Music to Students with Special Needs provides more resources.

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Image credit: (1) via iStockphoto. (2) Having fun in a music class. Photo by SolStock, iStockphoto.

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Few scenes in one’s life evoke vivid imagery. A generation’s historical memory can be reduced to a single significant moment—think Pearl Harbor, JFK’s assassination, 9/11. For gay and lesbian Californians of my generation, the State Supreme Court’s 2008 ruling in favor of same-sex marriage seemed initially like it might just be such a moment. As a well-adjusted gay man, happily partnered for over a decade in a relationship legally recognized through the state’s domestic partnership system, I did not anticipate the wave of emotion I felt upon hearing the decision. I had grown accustomed to the “separate but equal”(ish) system the state had constructed for me. I lived happily in a predominantly gay enclave in San Francisco and had grown accustomed to, even embraced, separation from “mainstream” heterosexual culture. Like most gays and lesbians in my generation (born in the 1970s, coming out in the 1990s), I had successfully navigated the psychological challenges of social and political exclusion.

One of the great achievements of the lesbian, gay, bisexual, and transgender (LGBT) movement has been the creation of communities in which a young lesbian can feel a sense of inclusion and commonality. LGBT communities offer her a space in which no explanation, no defense, and no apology for her sexual orientation is needed. These communities represent vital adaptations to a social structure in which the experience of sexual minorities and their ability to participate in cultural institutions—free from stigma and discrimination—is constantly relegated to a question.

What would it mean to reimagine that young lesbian’s life course in the context of a new cultural and political reality—a life course not characterized by the navigation of stigma but of the possibility for unapologetic self-expression? While the US Supreme Court may not be as concerned with the psychology of social exclusion as it is with the technicalities of “standing,” this question ought to be at the forefront of our national conversation, if we care at all about today’s LGBT youth, and if we hope for them a life course of possibility rather than limitation.

Today’s LGBT youth are coming of age in a radically different cultural reality than previous generations. On the one hand, they have access to far greater resources and far greater access to one another. Many of today’s youth experience diversity in sexual orientation as the “new normal,” as psychologist Ritch C. Savin-Williams suggested in The New Gay Teenager (Harvard University Press, 2005). Sociological studies in high schools in both the United States by C.J. Pascoe (Dude, You’re a Fag, University of California Press, 2007) and the United Kingdom by Mark McCormack (The Declining Significance of Homophobia, Oxford University Press, 2012) support this idea.

But the storyline about today’s LGBT youth is not so straightforward. As the justices were quick to suggest this week, social change is not linear and immediate but in an active state of debate. A popular refrain of marriage equality opponents has been that more time is needed for cultural conversation before a ruling that might apply to the entire nation. How might that young lesbian experience this debate about her own life course possibilities?

In 2011, the Institute of Medicine issued a report indicating that LGBT persons continue to experience health and mental health disparities relative to their heterosexual peers. The report coincided with a major review paper in the Journal of Research on Adolescence by Elizabeth Saewyc revealing that the “new normal” for LGBT youth does not necessarily translate into the privilege of an adolescence unburdened by victimization or psychological distress. In short, LGBT youth experience both greater support than ever and continued psychological distress because of continued societal stigma. Narratives of struggle coexist with narratives of liberation from societal stigma in a rapidly changing cultural context for sexuality.

As a culture, we are at a crossroads. Do we maintain the rhetoric of stigma and its policy implications? Do we suggest to today’s LGBT youth that their pursuit of happiness in the love and satisfaction of an intimate relationship is culturally inferior to their heterosexual peers? Do we suggest to them that they are lesser, defective, abnormal? Or do we use this opportunity to apply the anchoring political ideals of our nation—ideals like individual liberty and equality before the law—to a group whose long history of demonization has been accompanied by significant psychological struggle?

Here politics and science converge for the great “experiment” to be concerned with is not the consequences of same-sex marriage for society, but rather the consequences of social exclusion for the health and well-being of sexual minority persons. To summarize the evidence from social science: stigma and subordination psychologically harm LGBT people. Same-sex relationships provide meaning and happiness and are comparable to opposite-sex relationships. Many same-sex relationships actually show more equality in matters such as domestic labor and communication than opposite-sex relationships. The children of same-sex headed households fare just as well as those of opposite-sex ones. When the rights of sexual minority people are subject to a vote by the majority, they experience greater psychological distress as surveys conducted during anti-gay marriage amendment votes have illustrated. That young lesbian listening to the marriage equality debate has a psychological response to what it means for her life.

In short, the evidence to weigh is not whether marriage equality will somehow erode society as we know it but rather how marriage inequality interferes with the fundamental rights enshrined in our national narrative of political liberty and equality, subordinating an entire class of citizens and thwarting the possibilities of a life course free from stigma and psychological distress. Life, liberty, and the pursuit of happiness are not abstract concepts; they are lived psychological experiences—lived by LGBT people in spite of a social structure that conspires against them.

While I would never wish a different life course upon myself—my struggles define my identity—I would welcome a world in which young LGBT persons do not have to navigate the psychology of social and political exclusion. And I and other social scientists would welcome a world in which our political ideals are embodied in our concern for the psychological welfare of our nation’s LGBT citizens.

Phillip L. Hammack is Associate Professor of Psychology at the University of California, Santa Cruz. He is co-editor of The Story of Sexual Identity: Narrative Perspectives on the Gay and Lesbian Life Course (Oxford University Press, 2009) and co-editor of Oxford’s Series on Sexuality, Identity, & Society.

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Like the great and powerful Oz, filmmakers conceal themselves behind a screen and offer a mesmerizing experience that engages our sights, thoughts, and emotions. They have developed an assortment of magical “tricks” of acting, staging, sound, camera movement, and editing that create a sort of sleight of mind. These techniques have been discovered largely through trial and error, and thus we have very little understanding of how they actually work on our psyche. Scholars of “film studies” have thought deeply about the nature of movies, yet few scientists have considered empirical analyses of our movie experience—or what I have coined psychocinematics. Yet more than any other artistic expression or form of entertainment, we are captured by movies and involve ourselves with the characters portrayed, almost as if are in the scenes themselves.

How do filmmakers draw us into the drama and keep us riveted to the screen? How does film editing link events in an often seamless manner? How do movies drive our emotions, instilling suspense, laughter, horror, sadness, and surprise along the way? Why are movies so compelling? One’s first response might be: “It’s the story, stupid!” If the plot isn’t interesting or if we cannot identify with the characters portrayed, interest soon diminishes. Of course, how a filmmaker engages us into the plot is determined by a variety of factors: the acting may be superb, the visuals stunning, the editing seamless or interestingly quirky, the drama gripping, or the suspense overwhelming. For a scientific understanding, one needs evaluate these rather subjective features by developing a theoretical framework for empirical research.

Toward a scientific analysis of movies, I’ve come up with a simple scheme that captures the psychological features of our movie experience, which I call the I-SKE model. The name is an acronym for what I believe are four essential components of our aesthetic response to movies: the intention (I) of the filmmaker and three psychological components of the viewer: sensation, knowledge, and emotion. The I-SKE model was initially developed to describe our aesthetic response to visual art (see Experiencing Art: In the Brain of the Beholder). When we experience art, indeed when we experience anything, we don’t start from a “blank slate” as we are always applying our knowledge to new experiences, drawing on world knowledge, cultural experiences, and personal memories. Ernst Gombrich, the noted art historian called this influence “the beholder’s share.” With respect to movies, filmmakers play on our prior knowledge (of life and of movies) by offering an audiovisual experience that is part storytelling and part a simulation of how we naturally experience the world. The I-SKE model can be used to breakdown the beholder’s share into the sensory, conceptual (knowledge), and emotional features of film. Indeed, when these three components are running at maximum intensities we experience that satisfied feeling as the movie credits roll and exclaim, “that was fantastic!” Psychocinematics considers the impact of these I-SKE components and how they interact.

With the advent of brain imaging techniques, particularly functional magnetic resonance imaging (fMRI), psychological science can now link mental events with brain processes. Indeed, it is now possible to have individuals watch a movie in a fMRI scanner and record the brain regions that are active during the experience (something that was considered science fiction fantasy only 20 years ago). In this way, one can map psychological experience with brain activity. We must not, however, fall into a modern-day version of phrenology where bumps on the head are replaced by bright spots on a brain scan. We need to go further and develop theories that describe the functional dynamics of neural activity and how brain regions interact to enable us to see, think, and feel. Thus, psychocinematics offers an opportunity to consider our movie experience from a scientific perspective that connects minds, brains, and experience at the movies. In the end, we’ll need more than psychology and biology, as sociology, history, anthropology, and other relevant disciplines are needed to gain a broad understanding of the magic of movies.

Arthur P. Shimamura is Professor of Psychology at the University of California, Berkeley and faculty member of the Helen Wills Neuroscience Institute. He studies the psychological and biological underpinnings of memory and movies. He was awarded a John Simon Guggenheim Fellowship in 2008 to study links between art, mind, and brain. He is co-editor of Aesthetic Science: Connecting Minds, Brains, and Experience (Shimamura & Palmer, ed., OUP, 2012), editor of the forthcoming Psychocinematics: Exploring Cognition at the Movies(ed., OUP, March 2013), and author of the forthcoming book, Experiencing Art: In the Brain of the Beholder (May 2013). Further musings can be found on his blog, Psychocinematics: Cognition at the Movies.

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It may be hard to believe, but one of the most common and problematic mental disorders is ignored by the public and media alike. People — and reporters — breathlessly talk about depression, substance abuse and autism, but no one ever talks about antisocial personality disorder. Why?

Though better known as sociopathy, antisocial personality disorder, or ASP, affects up to 8½ million Americans and there is no cure, nor are there any good treatments. Psychiatrists like me who are interested in this disorder tend to be ignored and our concerns marginalized. The patients themselves can be difficult, and even unpleasant, and that limits interest. It is hard for people to be sympathetic toward those who tend not to arouse our concern. There are no poster children to point to.

Few mental health professionals are interested in the disorder and some run when a colleague tries to refer an antisocial patient to them. ASP is rarely discussed in medical schools, and few researchers take it on as a cause. Most telling, the National Institutes of Health (NIH), the government’s premier medical research organization, funds a grand total of two projects in which the term “antisocial” appears in the title. By contrast, the NIH funds hundreds if not thousands of studies on more conventional mental health topics such as schizophrenia, depression, anxiety disorders, and autism. How are we — as mental health professionals — to make headway in treating and preventing this disorder when the government does not lead the way?

First, let us consider what ASP is. Briefly, it is a disorder of chronic or serial misbehavior that begins in childhood and continues into adulthood, usually persisting throughout a person’s life. These are the rule breakers who see fit to violate society’s conventions. As children they fight with others, lie to their parents, and steal from the corner store. As adults, they abuse their partners or spouses, are irresponsible toward their children, and some are criminal. In the worst cases, some commit heinous acts of violence. Few of its sufferers are women, as it is predominately a man’s disorder. And sufferer is not the right word, because most antisocial persons do not “suffer” in the usual sense since they rarely believe anything is wrong. Their behavior is not the problem; society and its tiresome rules are the problem.

How did we arrive at this point? First, there is the lack of visibility. ASP is not on the public’s radar screen. While known to psychiatrists and psychologists for nearly 200 years in one form or another, few mental health professionals bother to make the diagnosis or to even make referrals for its evaluation or treatment. The public misunderstands the term antisocial, believing the disorder to relate to shyness, when it really relates to bad behavior directed against society. Finally, researchers tend to go where the money is. Since the NIH directs few funds to investigate ASP, why would an investigator study it? Take autism as an example. The amount of research exploded within the last decade when it became clear that the government was interested in the disorder. That could happen with ASP if the NIH changed its tune. Despite this deliberate indifference, over the past 50 years researchers have — mostly on their own time and money — consistently shown it to be one of the most heritable of disorders and to have a clear neurobiological basis.

Why should I and others care? Though under the radar, ASP isn’t going anywhere. It will continue — over time — to cost us billions and billions though its direct and indirect costs associated with law enforcement and criminal justice. Nearly all of us are victims of an antisocial person’s misdeeds; we fear them and even grapple with the disorder in our families. Now more than ever, psychiatry and society have the means to explore why some people turn bad, but progress will continue to accrue slowly until we begin to see ASP more clearly and commit ourselves to doing something about it.

Understanding the scope of ASP and coming to grips with it requires time and money. The NIH and other agencies must change their tune about funding ASP research and its many facets, particularly crime and violence. Priorities should include wide-reaching projects to explore its origins and search for methods to change its course. Geneticists must continue to investigate genes that might predispose individuals to ASP and determine how they function. Neuroscientists should work to pinpoint brain regions linked to antisocial behavior while identifying the neurophysiological pathways that influence its expression. Mental health professionals must overcome their own resistance to working with antisocial persons in order to develop new treatments. Last, we must focus attention on the group at highest risk of developing ASP: children with antisocial behavior. Improved understanding of their home life and social environment may lead to more effective interventions that may prevent ASP from developing. By treating and possibly preventing ASP, we can have a broad impact that ripples through society, thereby helping to reduce spousal abuse, family violence, and criminal behavior.

Donald W. Black, MD, is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy), Revised and Updated Edition. He is a Professor of Psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City. A graduate of Stanford University and the University of Utah School of Medicine, he has received numerous awards for teaching, research, and patient care, and is listed in “Best Doctors in America.” He serves as a consultant to the Iowa Department of Corrections. He writes extensively for professional audiences and his work has been featured in television and print media worldwide.

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The Sunday Times Oxford Literary Festival 2013 is in full swing, welcoming thinkers and writers from across the globe to our wonderful city of Oxford. We’re delighted to have over thirty Oxford University Press authors participating in the Festival this year! OUPblog will be bringing you a selection of blog posts from these authors so that  even if you can’t join us in Oxford this year, you won’t miss out on all the action. Don’t forget you can also follow @oxfordlitfest and check the event schedule here.

Kathleen Taylor will be appearing at the Oxford Literary Festival on Saturday 23 March 2013 at 2pm to discuss what the new science of the brain supremacy means for us. More information and tickets.

Q&A with Kathleen Taylor

What is the brain supremacy?
I use the phrase ‘the brain supremacy’ to  describe the increasing relevance of neuroscience. It foresees an era – whose birth is already well underway – when the balance of power within the sciences will shift from the natural to the life sciences, from physics and chemistry to the fast-moving sciences of the mind and brain. Neuroscience used to be a subfield of human physiology. It is now a fully-fledged research discipline, and its influence in everyday life is only beginning to be felt. As the era of the brain supremacy unfolds, it will change us in ways unmatched by any science outside the realms of science fiction.

The brain supremacy has been gathering pace for a while. It is driven by the convergence of three great technological advances: in computing power, in genetics, and in neuroimaging. Computing provides the ability to record, store and process the vast amounts of data generated by an organ made up of some 170 billion electrically-signalling neurons and glial cells. Genetics offers the promise of precise manipulation of those cells, switching genes on and off on demand, and controlling the activity of the proteins they encode with unprecedented accuracy. And neuroimaging has opened up the black box between the brain’s sensory inputs and its motor outputs, allowing researchers to study living human brains as they process and react to incoming data.

Why does the brain supremacy matter to you?
A change within science which pushes brain research up the status hierarchy may not seem important to anyone except scientists, but it is. The ways we respond to science, our expectations of its capabilities, our moral judgements of its achievements and our fears about it, all are shaped by ideas which have, so far, come primarily from the natural sciences. Think of a scientist, and chances are it’s Einstein or Newton who springs to mind – not Darwin, let alone a neuroscientist. Yet it is the neuroscientists who are likely to have the greatest impact on us in the 21^st century.

Why? Because in the brain supremacy, the material which researchers analyse and manipulate is not inanimate matter, nor even the living organisms used in animal research. The stuff of these new sciences is us, and that changes everything. The ability to understand and control a human brain, once we possess it, opens up extraordinary possibilities. Neuroscience is by no means there yet, but it has made extraordinary progress even in the last ten years. Yet the ethics of studying people, which ultimately come from medicine, are not the same as the traditional scientific ethics of studying material. We cannot simply react to brain research as we would to any other science, because its implications for human nature are so profound.

What new technologies will the brain supremacy provide?
I use the term ‘digitised neural experience’ (DNE) to cover all digitally-recorded measures of brain activity, and to make the point that brain activity has much to do with minds. (Change one, and you can change the other, even though we do not fully grasp the nature of the link between them.) There are two kinds of future DNE technologies: recording and programming. Once these are developed, they will give us the power, among other things, to lessen or heal the damage done by brain diseases, to record and share dreams, to achieve practical telepathy, and to reshape not only our bodies – as we do already – but our feelings, beliefs and personalities. What we now manage slowly or not at all, with education, experience and self-discipline, will be attainable much more quickly by technological means.

But isn’t this pure speculation?
The answer is: we don’t know. We do know that brain research has a long way to go before it is able to manipulate DNE as precisely as we would like. There are many difficulties in the way of precision thought control, and there may yet be some obstacle which proves fatal to the entire DNE enterprise. Ethical objections are easy to imagine, but given the attractions of DNE technologies, it is less easy to see how moral qualms will stymie their development. So by ‘obstacle’, I mean some scientific or technological limitation which stalls research progress.

At present, we know of no such limitation. We also know that ideas which, two decades ago, would have been derided as impossible are now being calmly considered in the research literature. For example, neuroimaging researchers have already begun to decode brain activity patterns, allowing them to know which image a person is looking at, or where an animal is in a virtual environment, simply by analysing brain data. Work is also being done on linking brain activity patterns to specific words, and to movements. This is the basis of ‘thought-controlled’ games, wheelchairs, and artificial limbs, which are already being made available to the public.

Why did you write ‘The Brain Supremacy’?
Neuroscience is the most fascinating science on the planet, because it is the science of us. Brains are not only amazingly complex organs in their own right, they are the physical ground of everything we cherish most. In this century, we may well achieve the capacities of DNE recording and programming, allowing us to manipulate living human brains with unprecedented ease and precision. That prospect is glorious, but, as so often with new science, it is also double-sided. There are the hopes of self-improvement and of healing dreadful brain disorders … and then there are the less pleasant uses of DNE control. Governments, the military and corporations are intensely interested in neuroscience. It isn’t hard to see why.

To ensure that we get the best from the new science, while restraining its darker side, we need much more public interest and involvement. Thus The Brain Supremacy expresses a sense of urgency, a need to catch up with the research. We need to talk about neuroscience, and to do that we need a guide to its cutting edge, and to the methods which will drive the brain supremacy.

Kathleen Taylor has written on a range of topics from consciousness to cruelty. Her most recent work, The Brain Supremacy: Notes from the frontiers of neuroscience, published in 2012.

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In the 1960s, about the same time that Albert Ellis was developing his original cognitive-behavioral therapy approach and William Glasser was developing his reality therapy (a cognitive behavior approach that evolved into Choice Theory), an educator named Louis Raths was developing a new affective-cognitive-behavioral counseling approach that eventually came to be called “values clarification.”

Raths noticed that young people who seemed apathetic, flighty, over-conforming, or over-dissenting in their behavior could become more purposeful, consistent, and zestful in their lives if they were asked to reflect upon their goals, purposes, and behaviors. He and his students Sidney Simon and Merrill Harmin refined and developed many ways that teachers and counselors could ask students “value-clarifying questions” and “values clarification strategies” to encourage them to reflect on what they prized and cherished, affirm their values with others, consider alternatives and their consequences, make freer choices about their lives, and act on their goals and beliefs in a consistent manner.

While developments and research on cognitive-behavioral therapies proceeded steadily over the decades, in the 1970s and 80s the focus of the values clarification movement stayed mostly on teaching, values education, and character education with youth. Although many of the methods and strategies of values clarification—such as voting, ranking, continuums, inventories, unfinished sentences, and the like—became staples in the repertoire of counselors and therapists, the utility of values clarification as a distinctive counseling approach was lost to one or two generations of new helping professionals.

In the 1980s and 90s, newer counseling and therapy approaches began to emerge on the scene, many of them utilizing concepts and methods of values clarification. Solution-focused therapy relies heavily on questions to help clients identify preferred goals, view their situation from an alternative perspective, consider alternative solutions, and evaluate coping strategies and solutions. Motivational interviewing, which has proven especially effective in alcohol and substance abuse counseling, uses clarifying questions and strategies to build on the client’s intrinsic motivation to change. Appreciative inquiry relies primarily on clarifying questions to help the client identify and capitalize on their strengths, vitalities, aspirations, possibilities, and core values as they set and achieve life and career goals. Acceptance and commitment therapy explicitly includes values clarification as a major component in their research-tested integration of western and eastern “behavior technologies.” Positive psychology recognizes that living according to one’s values is an essential element of life satisfaction.

I can’t help but be pleased that the importance of values clarification seems increasingly to be recognized as an important component in many different therapeutic approaches. Helping clients identify goals and priorities, make good decisions among competing choices, and take positive actions to achieve their goals and priorities—in a word, values clarification—is inevitably an important part of recovery, marriage and family therapy, career counseling, school counseling, pastoral counseling, financial counseling, and many other counseling and therapy foci. While values clarification is not a mental health counseling approach per se, it can be an important tool in psychotherapy when clients are ready to work on their recovery, set goals, and move forward in their lives.

So the question arises for me: Is it sufficient that values clarification seems frequently to be incorporated into many different therapy approaches and venues, or does it deserve its own renewed attention as a distinct counseling modality?

A partial answer to this question came to me in 2000, when I became chair of the Counseling Program at the Warner Graduate School of Education at the University of Rochester. I included the values clarification approach in my methods courses with both Masters students who were new to counseling and doctoral students who often had more counseling experience in certain areas than I did. Many or most of them loved values clarification: “It’s so practical.” “It’s so applicable to my work.” “Whether in individual or group settings, values clarification questions and activities make it so easy for individuals to respond and participate, even the quiet ones.”

So I became convinced that counselors, psychotherapists, psychologists, social workers, and similar helping professionals could benefit by being introduced or re-introduced to values clarification theory and practice, including:

• the focus on prizing (affective), choosing (cognitive), and acting (behavior)
• the seven criteria or valuing processes that fall within those three realms
• the difference between value indicators and values
• how to ask good clarifying questions
• using the “clarifying interview” in individual counseling
• the scores of practical values clarification strategies for individual and group work
• specific applications of values clarification to different counseling topics and settings
• the overall values clarification hypothesis and research
• the appropriateness of values clarification for multicultural populations and issues
• handling value and moral conflicts with clients

In the end, values clarification can be, and often is, used by itself or integrated with almost any other counseling or therapeutic modality. Better that helping professionals use it awarely and to its greatest effectiveness.

Howard Kirschenbaum, Ed.D., is Professor Emeritus and former chair of the Department of Counseling and Human Development, Warner Graduate School of Education and Human Development, University of Rochester. He is the author of Values Clarification in Counseling and Psychotherapy: Practical Strategies for Individual and Group Settings by Oxford University Press and is the author or co-author of additional books on psychology, education, and history, including Values Clarification: A Handbook of Practical Strategies, Readings in Values Clarification, and Advanced Value Clarification. He has given workshops and presentations on the values clarification approach to counseling, psychotherapy and education throughout North America and around the world.

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