Wednesday, February 4, 2015


When I first trained as a clinical psychologist in the Department of Social Relations at Harvard, it seemed peculiar at first that the program required Anthropology, Sociology, Social Psychology, Behavior Theory, as well as the expected specific practicum and clinical training. The idea seemed to be that clinical work cannot be separated from broad experience with everything human.

Clinical assessment itself had the usual lectures and practicum experience on symptom-based psychopathology, but also emphasized Robert White's and Henry Murray's approach of detailed life stories. Every life is a story that has to be understood from its beginning, adhering to Aristotle's advice that, "If you would understand any single thing you must observe it from the beginning." Mental life and its accompanying behavior and environments are complex and ever-changing; something only hinted at in a single hour of gathering the story. Good preparation is like good novels, something to be read with care.

Poetry also often informs us of mental life not otherwise easily understood. How better to understand grief than Shellley's Music When Soft Voices Die, or stream of consciousness and T.S. Eliot's Lovesong of J. Alfred Prufrock? In those moments in the office when patiently listening to the story of a family or patient, everything you know or believe informs how the story is eventually put together. An awesome responsibility. Great scholarship and classical learning does not completely prevent atrocious ideas as well as some profound ideas taking over the mind, like Dawkins' concept of mental viruses (as the history of psychoanalysis abundantly shows). But our culture has always valued learning as the foundation of healthy human life.

Back at Hopkins the early 60's the clinical process seemed straightforward: gather as much information in the time allowed, using tools of the trade such as interview, psychological testing, brief consultation, behavioral strategies such as Jacobsonian Progressive Relaxation, new ideas (at the time) such as Wolpe's hierarchical fear exposure, family social work, and so on. Randomized clinical trials formed the basis of the new developments in psychopharmacology. Psychiatrists, psychologists, and social workers shared the load as a team. Some of what we learned has been proven invaluable to the lives of patients, though some of what we learned has also been committed to the dustbin of history as evidence became available.

Much has changed since that time. We had no computers, cell phones, diagnostic structured interviews, rating scales or APPs. My first study involved a checklist of referral problems gleaned from the table of contents of a Handbook of Child Psychiatry. By changing the checklist into a scale and factor analyzing the results, I created a useful scale for gathering information and tracking treatment effects. But I never envisioned that the scales would be applied without the requisite training at the professional level, as a helpful tool, not an end in itself in writing the story. Recently we read of teachers who exaggerate the symptoms of troublesome children to insure that they receive drug therapy, thus increasing the financial benefits of a reward-based special education system.

Now something has happened that we never envisioned. Rating scales and clinical applications like Cognitive Behavior Therapy,  Self Examination of symptoms,  of mood, behavior states, thoughts and related activities, drug side effects, dietary choices, and more are being recorded on APPs for cell phones. These programs act like self-managing therapy or recording devices, that can also include physiological parameters like heart rate, blood volume, or even EEG. The patient has, in a sense, become their own doctor. The APP acts like an extension of the doctor's knowledge, but knowledge applied and evaluated by the patient.

But one question is troubling: Do they work? Could they be harmful as well as helpful? We have always assumed that various forms of mental illness are by definition subject to processes that involve more than ordinary problems of living. True, this assumption may be incorrect and also needs examination by empirical data. Can the explosion of reliance on new technology turn out to be harmful to the individual, or at the least an expensive waste of time? Could they further the over diagnosis and over treatment already a disaster in much of the mental health arena? It may seem lame to say, "Go ahead, let's try it until further research answers our concerns," but perhaps we should also become more Scottish at heart and say, Caveat Emptor!

Readers of this blog are already conversant with the new technology. I am curious how you all respond to the question above.