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1
What Changes?
What Doesn't Change?
TWO WORLDVIEWS are in collision. On the one hand, this is the age ofpsychotherapy and the age of self-improvement. Millions are struggling to change: We diet, we jog, we meditate. We adopt new modes of thought to counteract our depressions. We practice relaxation to curtail stress. We exercise to expand our memory and to quadruple our reading speed. We adopt draconian regimes to give up smoking. We raise our little boys and girls to androgyny. We come out of the closet or we try to become heterosexual. We seek to lose our taste for alcohol. We seek more meaning in life. We try to extend our life span.
Sometimes it works. But distressingly often, self-improvement and psychotherapy fail. The cost is enormous. We think we are worthless. We feel guilty and ashamed. We believe we have no willpower and that we are failures. We give up trying to change.
Trudy, like tens of millions of Americans, is desperate because she believes, quite incorrectly, that she is a failure. She finds herself even worse off after ten years of trying everything to lose weight.
Trudy weighed 175 pounds when she graduated from Brown a decade ago. Four times since, she has slimmed to under 125: Weight Watchers, Nutri-System, six months under the care of a private behavior therapist, and, last year,
Optifast. With each regime the weight came off quickly, if not painlessly. Each time the fat returned, faster and more of it. Trudy now weighs 195 and has given up.
In its faith that we can change anything, the self-improvement movement expects Trudy to succeed in her fight against fat, even though she is such an obvious loser in the weight game. On the other hand, there is a view that expects Trudy to fail. For this is not only the age of self-improvement and therapy, this is the age of biological psychiatry. The human genome will be nearly mapped before the millennium is over. The brain systems underlying sex, hearing, memory, left-handedness, and sadness are now known. Psychoactive drugs—external agents—quiet our fears, relieve our blues, bring us bliss, dampen our mania, and dissolve our delusions more effectively than we can on our own. Our very personality—our intelligence and musical talent, even our religiousness, our conscience (or its absence), our politics, and our exuberance—turns out to be more the product of our genes than almost anyone would have believed a decade ago. Identical twins reared apart are uncannily similar in all these traits, almost as similar as they are for height and weight. The underlying message of the age of biological psychiatry is that our biology frequently makes changing, in spite of all our efforts, impossible.
But the view that all is genetic and biochemical and therefore cannot change is also very often wrong. Many individuals surpass their IQs, fail to "respond" to drugs, make sweeping changes in their lives, live on when their cancer is "terminal," or defy the hormones and brain circuitry that "dictate" lust or femininity or memory loss.
Clay is one of many who ignored the conventional wisdom that his problem was "biological" and found just the right psychotherapy, which worked quickly and permanently.
Out of the blue, about once a week, Clay, a software designer, was having panic attacks. His heart started to pound, he couldn't catch his breath, and he was sure he was going to die. After about an hour of terror, the panic subsided. Clay underwent four years of psychoanalysis, which gave him insight into his childhood feelings of abandonment but didn't lessen the panic attacks. Then he was on high doses of Xanax (alprazolam, a tranquilizer) for a year; during that time he only panicked once a month, but he was so sleepy most of the time that he lost his two biggest accounts. So Clay stopped taking Xanax and the panic returned with unabated fury. Two years ago, he had ten sessions of cognitive therapy for panic disorder. He corrected his mistaken belief that the symptoms of anxiety (e.g., heart racing, shortness of breath) are catastrophic: symptoms of an impending heart attack. Since then he hasn't had a single attack.
As the ideologies of biological psychiatry and self-improvement collide, a resolution is apparent. There are some things about ourselves that can be changed, others that cannot, and some that can be changed only with extreme difficulty.
What can we succeed in changing about ourselves? What can we not? Why did Trudy fail and Clay succeed? When can we overcome our biology? When is our biology our destiny? These are the central questions I will address in this book.
A great deal is now known about change. Much of this knowledge exists only in the technical literature, and it has often been obfuscated by vested commercial, therapeutic, and, not the least, political interests. The behaviorists long ago told the world that everything can be changed—intelligence, sexuality, mood, masculinity or femininity. The psychoanalysts still claim that with enough insight, all your personality traits can be "worked through." The Marxist left, the "politically correct," and the self-help industry added their voices to this convenient chorus. In contrast, the pharmaceutical companies, the biologists mapping the human genome, and the extreme right wing tell us that our character is fixed, that we are prisoners of our genes and the chemicals bathing our brains, that short of powerful drugs, genetic engineering, or brain surgery, nothing basic can change: certainly not mood, or intelligence, or sexuality, or masculinity. These are all ideologically driven falsehoods.
Here are some facts about what you can change:
.Panic can be easily unlearned, but cannot be cured by medication.
.The sexual "dysfunctions"—frigidity, impotence, premature ejaculation—are easily unlearned.
.Our moods, which can wreak havoc with our physical health, are readily controlled.
.Depression can be cured by straightforward changes in conscious thinking or helped by medication, but it cannot be cured by insight into childhood.
.Optimism is a learned skill. Once learned, it increases achievement at work and improves physical health.
Here are some facts about what doesn't change:
.Dieting, in the long run, almost never works.
.Kids do not become androgynous easily.
.No treatment is known to improve on the natural course of recovery from alcoholism.
.Homosexuality does not become heterosexuality.
.Reliving childhood trauma does not undo adult personality problems.
To deal with what we cannot change, the first step, all too often evaded, is to know what about ourselves will not yield. But that is not the end of the matter; there are usually ways of coping. Much of successful living consists of learning to make the best of a bad situation. My purpose here, in part, is not only to point out what will not easily change but to impart the skills for coping with what you cannot change.
This book is the first accurate and factual guide to what you can change and what you cannot change. Since I am going to argue that so many loudly trumpeted claims about self-improvement, psychotherapy, medication, and genetics are not to be believed, that some things about you will not change no matter how much you try, but that other things will change easily, you should know a little about my qualifications.
I have spent the last thirty years working on the question of "plasticity," academic jargon for what changes and what doesn't. I have worked both sides of the street. I started my academic life in the field pretentiously called "learning." Like most of the social sciences of the 1960s, the psychology of learning was enthusiastically environmental, its ideology a reaction to the still-fresh nightmare of the genetically minded Nazis. Just arrange the rewards and punishments right, learning theory held, and the organism (pigeon, adult human, rat, rhesus monkey, or toddler—it mattered so little that we simply called all of them "S's," for "Subjects") would absorb whatever you wanted to teach it.
My years in the learning laboratory taught me that there were many things organisms wouldn't learn no matter how ingenious the experiment. Rats wouldn't learn that tones predicted poisoning, and pigeons wouldn't learn to peck keys to avoid getting shocked. (Humans are even more resistant to change—but more on that later.) My first book, The Biological Boundaries of Learning (1972), set out a theory, "Preparedness," of how natural selection shapes what we can and cannot learn. Evolution, acting through our genes and our nervous system, has made it simple for us to change in certain ways and almost impossible for us to change in others.
With the constraints that evolution places on learning very much in mind, I had to pick my problems carefully. I was and I am an unabashed do-gooder. I wanted to discover things that would relieve suffering—leaving knowledge for knowledge's sake to other, purer souls. Some psychological suffering seemed to me unyielding, unchangeable because of biology. Other problems seemed more tractable, solvable if only I was patient enough, worked hard enough, and was clever enough. I had to discover the "plastic" problems on which to work.
I chose to work on helplessness, depression, and pessimism. Each of these, I found, could be learned and could be unlearned. In 1975, I wrote Helplessness: On Depression, Development, and Death. Its focus was on how helplessness was learned in the wake of uncontrollable bad events, and how this posture could devastate the rest of one's life. My most recent book, Learned Optimism (1991), was very much the opposite. It spelled out fifteen years of my research documenting the bad news: Habits of pessimism lead to depression, wither achievement, and undermine physical health. The good news is that pessimism can be unlearned, and that with its removal depression, underachievement, and poor health can be alleviated. My present research program is trying to prevent America's most costly mental illness—depression—rather than waiting to attempt cures after it strikes. All this is very much in the spirit of the age of self-improvement and the age of therapy.
A recurring theme of this book will be the need for truth in packaging in psychology and psychiatry; so I had best start by laying out my biases and my background.
The nature of the beast. This book is about the psychological beasts: depression, anxiety, stupidity, meanness, traumatic stress, alcoholism, fatness, sexual "perversion." When I was a callow learning theorist, I knew I was stalking after those beasts. I did not then realize that to understand them I had to take into account another beast, the human beast.
My ideology told me that environment is completely responsible for the psychological beasts. Stupidity is caused by ignorance; provide enough books and education, and you will cure stupidity. Depression and anxiety are caused by trauma, particularly bad childhood experience; minimize bad experience, raise children without adversity, and you will banish depression and anxiety. Prejudice is caused by unfamiliarity; get people acquainted, and prejudice will disappear. Sexual "perversion" is caused by repression and suppression; let it all hang out, and everyone will become lusty heterosexuals.
My bias now is that while this is not wholly wrong, it is seriously incomplete. The long evolutionary history of our species has also shaped our stupidities, our fears, our sadness, our crimes, what we lust after, and much else besides. The species we are combines with what actually happens to us to burden us with psychological beasts or to protect us against them. To understand and undo such malevolent effects, we must face the human beast.
No sacred cows. This book walks a political tightrope. On one side is the racist segment of the right, fervently hoping that intelligence, femininity, and criminality are all entirely genetic. On the other side are many aging 1960s liberals and their "politically correct" campus heirs, condemning all who dare to speak ill of victims; failure, they say, results from poverty, racism, a bad upbringing, a malevolent system, under-privilege, deprivation—from anything but oneself.
My loyalty is not to the right or to the left. I have no patience for their sacred cows or their special pleading. My loyalty is to reasoned argument, to the unfashionable positions that deserve a hearing, to the thoughtful weighing of evidence. I realize that much of what I will say in this book is grist for the agendas of both political positions. I believe that facing the beast entails airing unpopular arguments. When the evidence points toward genetic causes, I will say so. When the evidence points toward a bad environment or bad parenting as responsible, I will say so. When the evidence points toward unchangeability, I will say so. When the evidence points to effective ways of changing, I will say that too.
Outcome studies as best evidence. Suppose for a moment that an epidemic of German measles is predicted. You are pregnant and you know that German measles causes birth defects. Two vaccines, Measex and Pneuplox, are on the market. A famous Hollywood star says on TV that she was given Measex and didn't get German measles. An Olympic sprinter also adds her testimonial. Your best friend has heard good things about Measex. Pneuplox, on the other hand, is not advertising. But it has been tested in what is called an outcome study, in which it was administered to five hundred people: Only two of these people contracted German measles. Another five hundred received a sham injection: Twenty-eight of them got German measles. Now assume that Measex has not been so tested. Which vaccine do you want? The one that has passed a rigorous outcome test, of course.
Making up your mind about self-improvement courses, psychotherapy, and medications for you and your family is difficult because the industries that champion them are enormous and profitable and try to sell themselves with highly persuasive means: testimonials, case histories, word of mouth, endorsements ("My doctor is the best specialist on X in the East"), all slick forms of advertising. Just as this is no way to pick a vaccine or to decide on whether to have chemotherapy versus radiation for cancer, this is no way to decide on whether to try a particular diet, or whether to send your father to a particular alcohol-treatment center, or whether to take a particular drug for depression or to have psychotherapy. Much better evidence—outcome studies—is now often available.
In the collision between self-improvement and biological psychiatry, the two sides have until recently used different sorts of evidence. The biological psychiatrists started with case histories but then built up to outcome studies—comparing a treated group with a group given a sugar pill, a placebo. The self-improvement and psychotherapy advocates still rely, for the most part, on single case histories and testimonials: before and after snapshots of some formerly obese person, a dramatic case report from a professional football player in Alcoholics Anonymous, a case of sudden recovery from profound depression following an angry confrontation with
Mother. Case histories make absorbing reading, but they are clinically very weak, and, usually, self-serving evidence.
