Unawareness Versus Denial

Grim's recent post Blindness put me in mind of things I wrote years ago.  This was the first post in what eventually became the series "May We Believe Our Thoughts." I don't think I'm going to reprise much of that, but I thought I would put this in anyway, partly because of the comments there.

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Because of the neurological research coming out over the last decade or two three, psychiatry is increasingly making a distinction between denial and unawareness. Some of the research is being done up at Dartmouth MS by folks I admire and used to work with, so I keep up with this more than other areas.

Everything has been in the "denial" category since Freud, or before: the idea that mentally ill people really do know, at some level, what reality is, but hide it from themselves. Therapy was a way of developing insight, and having the courage to accept the unpleasant.

Unawareness, in contrast, is the idea that certain brain dysfunctions make the owners of those brains unable to see their illness, no more than a blind person can see, or even more exactly, than a color-blind person can distinguish colors. Like an amputee who feels a phantom limb, or like Oliver Sacks, losing the sense of ownership of a limb after injury, they cannot perceive their illness, regardless of the evidence submitted. Dr. Flashman gave the example of the patients who believed he had implanted chips in their brain, shown their chipless MRI's. The responses were varied - my sort of chip doesn't show up...that's not my MRI...you doctored the photo... but none were able to muster even a 0.1% acceptance of the no-chip idea. Not even in theory. Not even as a "what if" scenario.

We are moving lack of insight from the "denial" pile into the "unawareness" pile, for psychotic disorders certainly, but even for mood disorders when they are untreated. How far will this go? Will it turn out that no depressed people ever respond to any offered advice or insight, but only to the intervention of attention, of exercise, of medication, of practicing agency? Lincoln's comment that people are about as happy as they make up their minds to be might turn out to be completely untrue, and useful only for the reminding the folks outside the depression that nothing, absolutely nothing they advise is going to have the slightest effect.

I am increasingly convinced of this for many illnesses, and it makes me feel shame at the conversations I have had over the years with patients, attributing (usually, but not always, unconsciously) their lack of insight to some stubbornness or cowardice on their part - a refusal to engage reality rather than a biological inability to perceive it. It's not just a waste of time. It's thirty-plus years of unnecessary cruelty.

If you absorb this, you will see that it makes things both better and worse. If the patient is not going to be convinced, whether you explain for two seconds or two hours, why bother to give any explanation at all? Or if you listening to her for two hours will make no more difference than listening for two seconds, why listen at all? Isn't it just a waste of time and ultimately cruel, pretending to a patient that her opinion makes the slightest difference when if fact it doesn't? So let's just ignore everything she says until we get a guardian then, and hold her down and give her medicine and be done with it. Why any charade?

I don't think it takes much imagination to see that as a chilling scenario, and an enormously bad precedent to set.

But is badgering a deaf person because they can't hear any better? Because even if the mental health practitioner is speaking in the kindest tones, is really rooting for the patient to "get it," and has the best intentions, if we really think that underneath it all they are denying reality, that some trick or intervention on our part will help them turn the corner and begin to see, then badgering is what we are actually doing.

It gets worse. It may apply to a high percentage of all beliefs, not only to mental illness.

Update: Roper's comment reminds me that I have at least a half-dozen professionals reading here, so I should provide some links. Xavier Amador looks like he'd be pop psych, but he is not. His books cover a fair bit of the brain research. (as of 2011)

Laura Flashman

Thomas McAllister

Rethinking Schizophrenia

I has already mentioned recently my great approval of including the peer-support model in schizophrenia treatment. Of course, this presumes some acknowledgement by the sufferer of some degree of symptomatology. Those with complete lack of insight, or anosognosia, will have trouble availing themselves of this resource. But it is gratifying to see some positive press for this in popular media. The Sunday NYT has Keris Myrick's story. She has found that a full schedule and challenging herself is better life treatment than low-pressure, ease-into-it jobs. She uses other coping mechanisms as well, including peer support. The video isn't that great, but the story is good.

The Neurodevelopmental Hypothesis would seem to be an opposite at first. That approach, focusing on early detection and treatment, carries more than a whiff of "once you've got symptoms, you're already screwed and it's too late" about it. But that's an inaccurate reading, a leaping to conclusions.

Sometimes antipsychotic medications do magic, and if you are lucky, the side-effects aren't too bad. But really, they are often limited in what they can do. Hence the more recent focus on prevention and managing symptoms.

Dunning-Kruger Again

The Dunning-Kruger Effect makes its appearance again, over at Futurepundit, which asks whether geniuses are equally susceptible to this illogic.

Anosognosia Series

Errol Morris, filmmaker and writer, seems to be one of those brilliant people who are often wrong, but inspired enough to break new ground. He had a five-parts series in the NYTimes about anosognosia which folks might find interesting.
Part I
Part II
Part III
Part IV
Part V

She's More To Be Pitied Than Censured

Setting the stage...

I was sent a Cynthia Boaz HuffPo column. You can see that her focus is peace and change, nonviolent studies, that sort of thing. Just to kick her right up front, I direct you to her articles on how encouraging Egypt's February (sorta) revolution was (How'd that work out?), and how evil it was to leap to the conclusion that Fort Hood shooter Nidal Hasan's "motive was jihad and that the murders fell into the category of political terrorism," except of course, that this is exactly how things turned out. Why would I start out by slamming her, when my purported goal is to try and see her actions in a different light? Perhaps I'm just not so nice as I hope to be. But my own thought is that the amazing wrongness of these essays is what drove me forward to think more deeply.

Had I written such essays in a national, public setting and then been so quickly proved wrong, spectacularly wrong, I would be ashamed to appear out in writing public again. These are not Strong Opinion Pieces with which one might disagree, nor are they areas where she got things partly right and partly wrong.

She's not the only one, of course, and I'll warrant that if challenged, she and others could come up with elaborate rationales why what they said was understandable in context and still containing much worth listening to, etc. But in all normal circles - at work, in school, at church, in the neighborhood - making pronouncements like this and then having them served to you to eat just a bit later would cause us to slink away. What gives?

(If you really want to torment yourself, you can try On The Moral Depravity Of Capitalism In 21 Tweets. As thoroughly vacuous an essay as you will find.)

The essay sent to me, however was on the topic of how Fox "News" brainwashes its viewers to be dangerously stupid, and what a dire situation that is for the future of the republic.

Just a word or two on that. "News" in quotes. The first sentence includes the phrase "nothing more sacred..." Yet she is complaining about the attempted manipulation by others. When I read this language, I don't envision brave, unclouded souls speaking Truth to Power. I don't have images of stalwart faces staring off to the horizon, resolute and stern. I see Victorian women with wrists to the forehead, looking for fainting couches. Or is you prefer a deeper historic allusion, a David Garrick production of "The Merchant of Venice," Portia with heaving bosom. Or best of all, the Tragedians of comedy: Henry in "The Fantasticks," or Jack in Chapter 13 of Lewis's The Great Divorce.

So if I were to follow my usual script, I would excoriate her for being such a dangerous, violence-enabling airhead. I would make my usual demurrer that most liberals are of course not this stupid, noting only that they give such folks far too much credibility; that more lefties have some element of this than admit it to themselves, etc, etc. Yeah, fine. But I've said that for years, and is anything any better? Do we know any liberals who have, on the basis of being trounced intellectually, asked themselves "I wonder if there is even a 1% chance that we are wrong, not just in method or strategy, but in core principles?" Of course not.

Another possibility
As I am currently primed to consider anosognosia and the Dunning-Kruger Effect, I wondered why intelligent people - for this sort of liberal is usually intelligent in some sense: educated, facile with words, familiar with popular culture references* - thinks this way.

The second article sent with this one, plus a discussion at Althouse about music therapists, brought it into focus. The other article was about a team of people sponsoring an event in San Luis Obispo displaying quotes from holy books and having people guess which one they were from. The point being, of course, that there are some nice things said in the Quran, and therefore Muslims aren't really evil. A Methodist minister was involved in the design.

Reality check here: Anti-islamic prejudice in SLO is responsible for precisely none of the problems in international relations. What type of insane mind thinks that running such a program has any effect whatsoever? Then I remembered the music therapists, which reminded me of aromatherapists and "bodyworkers" and the artist in NYC who made female superhero sculptures after 9-11 so that women would feel empowered and safer. People pretend that what they do is useful, because it's all they have to keep away the night.

Cynthia Boaz is like that kid in the country song who wants to buy red shoes for his dying mother, but only has thirteen cents. "But it has to be enough, mister! It's all I've got!" Yeah, I know, there are other stories with that same plaintive cry, the wail that one is giving all one has, how can that not be enough? The world is dangerous and evil people want to kill us. We cannot bear to do nothing, so we employ a variety of psychological fantasies to keep the horror at bay. We blame ourselves; we pretend our paper swords are deadly; we declare the evil already defeated. It's just our pathetic, human nature selves.

This attitude can be noble, pathetic, or destructive in the human soul. There have been dramatically beautiful works of literature, as well as a thousand saccharine but uplifting stories, about those who gave their loaves and fishes and changed the world. It can be. But all good things can be made dark, and this one goes to especial darkness. The first key is humility. There is a difference between knowing that one only has thirteen cents, or a few loaves and fishes, or mere hobbit-strength to battle against evil - and claiming that such items are the great power that enables you, the elevated and noble, to hold the dark at bay. And still worse is the attitude which says that all those others are getting in the way of you and your thirteen cents conquering the serpent with your all-purpose goodness, and those others must be brought to heel and made to worship at altars you direct.

Yes, such things can go wrong. All good can be poisoned. But for the moment, have pity on the Cynthia Boaz's and Cindy Sheehan's and earnest rescuers. They at least started out loving the poor before they became addicted to the pleasures of kicking the powerful. They started by hoping everyone could get along, like in the movies, before the resentment of not being Princess overtook them.

75% chance of more to follow.



*Less-popular culture, such as anything between Sumeria and 1950, less so.

Paranoia

One of my paranoid patients uncovered the site Are You Targeted in his searching the internet for proof that he is being harassed by Hollywood and popular music, with messages directed specifically at him. He takes the existence of this site as evidence that his paranoid delusions are true: See, this is happening to other people, too! That different things are happening to those people, and they each have different experiences from each other, with only minor overlap, fazes him not. It's all tied in together somehow.

(The photo is from Ocala, FL)

My other really bright paranoid patient - she was a software developer up until a decade ago - has a different, nonelectronic set of delusions. A homeless person has been stalking her for at least three years, across three states, and recently revealed his existence by mistakenly leaving a purse she had lost in 2007 in a box in her apartment.

Here's the saddening, infuriating, and fascinating part. Both of them are now on medication, and are far more organised and relaxed. Both are able to coherently put on paper or into speech what they were unable to only a month ago. Then, additional notes up the side of the page, or between lines, or underlined and arrowed onto the back made their work unreadable. Now they can write in sentences and paragraphs. (I am overdrawing that somewhat, but the difference is dramatic.) Yet their delusions are absolutely untouched, with the possible exception of the fact that no new material is being added.

So there are two - at least two - parts to the illness, one which is treated by the medication and another which is untouched.

Chomsky

People are getting exercised this week because of Chomsky's comments in the magazine Guernica. (Wonderfully ironic title, recalling an event of real terror by fascists that was nonetheless exaggerated by leftists and has enormous symbolic meaning for them, as opposed to, say, their own execution of 20% of the priests and nuns.) Because people take him seriously, I should probably get more worked up about Chomsky myself. Yet I consider him disturbed, as if something organic might be wrong with him, and attacking him seems rather like pushing the guy in the wheelchair down the steps. We have spoken recently about anosognosia, and he exhibits something like that. Whatever happens, it is the West, especially America, especially capitalism that is at fault. There is never even a 1% deviation from this line, and as I have noted, an inability to see even a 1% reasonableness in another POV is itself pathological.

If there is a rape, then America was wearing short skirts, unless they were the active party, in which case they were violent and conscienceless rapists. If America is trading with a country and it does something evil, it was because of their contact with America, but if we don't trade with them, that is the cause. If we are on good terms with a government, then we are complicit in any of its evil acts. If we do not support it, then it is still not at fault, because we have driven them to extremism in opposition. It's just silly and predictable, and I would see no need to even mention it, except that folks take him seriously, and he does seem to be only a more intense version of other leftists who find can no good in us, nor any moral agency in others. It's a rather fun position to take, of course, for whenever others take the slightest bit of credit for good action or self-congratulate in any way, you can shoot them down and be morally superior, pointing out that they are in fact quite evil. Tastes great. Less filling.

It is also ultimately a self-defeating argument, if one sticks to logic. If we are to blame for everything, then we are to blame for nothing. There becomes no standard of measurement, no comparison of good and evil. I have little interest in how he got this way, whether it is some self-hatred, or a genuine compassion for the downtrodden that went off the rails, or a tribal loyalty to a narrow group; these things perpetuate for different reasons than they start, I think, for the neurology takes over and they become unable to even see another POV.

May We Believe Our Thoughts? Part I - Revisited

Here is a speech given by Xavier Amador, who I mentioned before, on the subject of anosognosia. It is lengthy, but excellent. And for those of us who have been doing this wrong for years, it is absolutely heartbreaking to listen to. I don't know if I can learn this.

May We Believe Our Thoughts? Part VI

I spoke about anosognosia today for ten minutes or so with a colleague, with specific reference to our patients, then more tentatively, about some previous department members who were known for ridiculously overvaluing their skills, and displaying no insight into even mild criticism. She took the point and understood immediately, and as I related it to a larger context, she started dropping in political comments. It was standard issue liberal boilerplate, about how people believed Sarah Palin even though that was obviously ridiculous - not specifics, of course - and people asking for Obama's birth certificate insisting he was born in Kenya - perhaps not seeing that one might ask on general principle. I let these pass, and several other stock items as well, but when she mentioned that legislators were so stupid not to address the revenue side and pass a sales or income tax (that's liberal boilerplate in NH), I ventured to mention that I thought in the long run that would lose money.

I didn't get to complete a sentence from there on in, and was trying to answer a barrage of strawmen, false choices, and rewording what I was trying to say into things she preferred to answer. I was quite subdued in what I actually said, but I could tell the mere challenge was ringing bells.

I will note, because it is key, that this is A) an intelligent, highly competent person and B) a person who immediately understood the general idea of extreme unawareness and worked with the concept independently after I had brought it up. I have little doubt that if forced to make a coherent, positive case for liberal ideas without resort to cliches, she could, on her own time, produce it. At least, I have little doubt that she was capable of this at one time. We may lose that if we rely on the conventional wisdom too long. But in the moment, it was a stunning non-understanding, driven primarily by unwillingness to hear the ideas out.

Now, I've done that myself before. I dare say there are subjects where I do it often, though I hope I self-monitor well-enough that I retain some ability to question my conclusions, even at my worst. But the point is that unawareness is not a general inability to be disagreed with, but can be specific to single areas. We might be open-minded on some things and closed-minded on others. That would suggest that unawareness cannot be a single brain area that is broken, and seems to drive us back to mind-explanations rather than brain-explanations.

I just noticed how apt that open and closed metaphor is for this discussion, though it is not a recent phrasing.

I propose a modification - I doubt I am the first to think of it, though I have not seen it before - that there is a brain mechanism nonetheless, and at a threshold point, unawareness becomes absolute. If we take the analogy of eyes and focus, it is actually a good thing for the two eyes to see things just a bit differently. It gives the brain more information, such as depth. But as data from the two eyes gets farther and farther apart, the brain is confused and striving to achieving a coherent vision, progressively disregards the data from one eye, until it may ignore it altogether.

The data from the remaining eye is now all-conquering. A marginal improvement in the bad eye may have no effect, or no immediate effect.

Thus, the more conflict between visions, the more certainty that the brain will resolve this with an unmovable view. Play that out in terms of a dominant culture of belief - media, social group, opinions of educators - providing one set of explanations, and the brain's rejection of the possibility that the strong eye could misperceive, and univision is not only possible, but the most likely possibility.

History seems to bear this out, that the dominant culture of anything is going to have significant blind spots that will not be moved. That's not just Arts & Humanities tribe members, but any group. The prevailing view of evangelicals, however right it might be in a dozen places, will have at minimum a place or two where they are not only wrong, but wildly wrong and unable to perceive that. (Insert mainstreamers, liturgical churches, whatever, in that slot.)

It holds for science in any field, as we can never see at the time but can always see in retrospect, wondering how supposedly data-driven people can miss the obvious. It holds for military strategists, stock investors, NFL scouts. The most likely scenario is a large blind spot.

Which sucks, of course, because that naturally means any and all of us.

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Related: I was browsing rather aimlessly through the New Testament, looking for examples of Jesus or Paul speaking of people who no longer having the ability to choose the right, but are in darkness because hey, they're in darkness and that's what happens. (First John 1-2 have a lot of that.) I still plan to relate that to this topic, but I got caught in this similar idea, and decided to try on applying it to the Gospel of Matthew. Pretty surprising stuff. If you hold that idea in your head, that if one is able to admit weakness, admit sin, admit wrongness at all, then one just might still be able to hear the Good News, but those who can't, just can't, because they are too far gone of their own previous choices, new shadings on a lot of scripture emerge. I'm going to push this idea further and see if it holds up under pressure.

My Uncle Again

Uncle Dave sent along a recent rant purportedly by Jesse Ventura. I thought he was sending it as an example of how insane the right-wing and Tea Party are, and I thought it sounded bogus. Searching the web I can see it attributed to Jesse, but it has the ring of someone else's rant, with Ventura's name tacked onto it.

Doesn't matter, really. When I dismissed it as insane...well I'll quote the email directly:

AVI: Did he really write this? I can't find that it's an urban legend, but it smells odd.

UncaDave: Yeah It does smell odd But so what
More often than not. you focus on the author
But not on what he says What difference does it make who writes? Even the marginals like Ventura (or his ghost writer ) may say something worthwhile
In which particular do you disagree with him?

AVI: Good heavens! All of it. It's insane. He talks about vague poisoners and robbers, calls them elites, and everyone can fill in the blanks with their own enemies. He's some guy they put away in a home, muttering about the commies, or the corporatists, or the jews. (For confirmation, look at the comments at the link.)

UncaDave: A continuance of attacking the author and ducking what he says

So I took the bait, and fisked the entire Ventura essay. Hope you have fun.

You who, even approximately, is this "you" he is speaking about? control our world. No, no one does. Power is diffuse.
You’ve poisoned the air we breathe, and yet Jesse lives and prospers, Funny.
contaminated the water we drink, is he talking about 1973 or something? What water? Where? Draining aquifers is the problem he should worry about
and copyrighted the food we eat. As opposed to breeds of cattle or tomatoes for the last two centuries? General Mills? Nestle? Or does he mean genetically-modified foods? What's his objection to them, other than some gut sense that they shouldn't be...well, I can't tell exactly. What the hell is he thinking is wrong? Is it 1999 again?
We fight in your wars Who? I'm still not getting it. Afghanistan and Iraq were popular wars at first - you could make a good case that the politicians fought them because the people demanded it, then they got unpopular after three years, as wars always do. If you mean Libya, I might agree.
die for your causes what causes does he mean? Whether one thinks the wars were about punishing bad guys, bringing long-term peace to the ME, or just grabbing some oil, those are pretty popular causes with Americans. I'd question the methods long before the causes. Those are pretty good causes. As wars go, those are way better than average reasons.
and sacrifice our freedoms to protect you. What freedoms were sacrificed? Airport searches, I'll grant. But the worrisome surveillance issues stem aren't particularly war-related. Yet who got protected?
You’ve liquidated our savings, OK, he must mean the government here, then, not businesses or the wealthy. Whatever else you might say about Walmart or GE or Microsoft, they haven't liquidated savings. And I'd say "eroded," not liquidated, anyway.

Hey, if this is the government that he has been talking about, then maybe Jesse and I have some common ground!

destroyed our middle class when did this happen? I must've missed it on the news, is it 1933 again?
and used our tax dollars to bailout your unending greed No we bailed out unending stupidity and I'm not sure who benefited, except unions and a lot of folks in government.
We are slaves to your corporations I pick Disney, then. I'll be their slave. Or Apple.
zombies to your airwaves okay, that one is starting to sound like my paranoid schizophrenic patients,
servants to your decadence. I'm trying to think what particular decadence I am enabling this year. Unless it's 1913 he's talking about. Is he channeling William Jennings Bryan?
You’ve stolen our elections - okay, that's the Democrats, but even I don't think they've stolen a lot of them. Maybe a handful,
assassinated our leaders - The 1960's? Is that the answer to the puzzle?,
and abolished our basic rights as human beings. And yet no one has locked Jesse up, despite his being insane. And I ate the dinner I liked, and sit typing at a computer.
You own our property So it's banks that are the problem, maybe,
shipped away our jobs, and shredded our unions See auto bailouts, above. And union member are about the only group with pensions now.
You’ve profited off of disaster Someone made money on....Katrina? Gulf Oil Spill? Or Japan? Or the tornadoes? I think those were pretty much all loss. Hiram does make some overtime whenever we have a blizzard, but we don't begrudge him that, he works hard for it
destabilized our currencies more than one? Maybe it is Bryan and the Free Silver party he's channeling,
and raised our cost of living. Only if he means government.
You’ve monopolized our freedom I have no idea what that means,
stripped away our education, Naw, the kids pretty much do that on their own

Everyone get ready to block those clustered metaphors...
and have almost extinguished our flame . We are hit… we are bleeding… but we ain’t got time to bleed. We will bring the giants to their knees and you will witness our revolution!

Bipolar

Charlie Sheen is an actor, right? I've heard his name for years, but I don't know if he's movies or TV. He must be pretty good, I suppose, if he's been around this long. Drugs keep getting mentioned, so the more accurate diagnosis wood be substance-induced mood disorder. I'm assuming he's quite liberal, because the tone of criticism is different than it was for Mel Gibson.

The sports radio guys were talking about some recent meltdown he's been having, and were laughing over his quotes. Welcome to my world. I went back and forth between being bored - I have heard a lot of bipolar guys talk like this - and embarrassed for him and the people laughing at him. Our new admission this morning had a similar presentation. Not all people going through mania are so entertaining, I suppose, but this type of conversation flows naturally from the tangentiality and expansive feelings of mania. It's like laughing at the crippled kid.

If he didn't have oodles of money this whole picture would look different.

So, this is the unofficial mental health awareness week.