disease


I attended a lecture today about addiction where the lecturer claimed that the American Medical Association requires that a phenomenon meet the following criteria to be considered a disease:

1) It must be progressive

2) It must manifest identifiable symptoms

3) It must occur chronically in affected individuals

4) It must be fatal if left untreated

That makes some things obvious diseases. Cancers, for example. There are many things that we consider diseases that do not fit these criteria, though. I believe that obesity, for example, is not officially considered a disease because it is not fatal. It’s correlated with many fatal conditions but isn’t fatal on its own. Most mental disorders fail to meet this criteria too. Anorexia is fatal if untreated, but anxiety disorders, dissociative disorders, ADHD, learning disorders, conduct disorders, psychotic disorders, and dissociative disorders and many others are not. There is a pretty good case to make for  alcoholism and some other addictions meeting these criteria. Disorders that are associated with suicidality, too, might qualify, like severe depression, and possibly “gender identity disorder,” though GID may not be progressive and so fail the first criteria.

Advertisements

I’ve been working with the University of Oregon Men’s Center since last spring, helping out with their research projects. During one of our last meetings, a couple MBA students pitched us the idea of growing mustaches for “Movember” (Mustache + November) as a way to increase awareness of prostate cancer. We went for it, so I’m six days into a mustache. (If you want to see the final product, read at least the last paragraph in this post.)

Here are the “Rules for Participants” from the Movember website:

1) On Shadowe’en (October 31st), the complete moustache region, including the entire upper lip and the handlebar zones, must be completely shaved.

2) For the entire duration of Movember (Movember 1st – 35th inclusive), no hair shall be allowed to grow in the goatee zone – being any facial area below the bottom lip.

3) There is to be no joining of the moustache to sideburns.

4) Failure to conform to all of these rules may, at the discretion of the official Movember Committee, result in instant blacklisting and may void invitation to the end of MOnth festivities (this year lip-marked for Movember 35th!)

5) Movember Committee accepts no responsibility for lost jobs, rashes, food/beer encrustments or any other such mishaps caused to the wearer (or his partner) of a Movember Moustache. You grew it yourself.

So I’m growing a mustache and it’s a little terrifying. I think I look silly. I wonder if my clients will be able to take me seriously. And this is the first time that I’ve resented my therapist costume. In my street clothes I can (maybe) pass as a moderately hip guy who’s growing a mustache because it’s silly. In my therapist costume–khakis, button-up shirt–I look like nothing but an overly earnest businessman who is clueless about the fashion implications of a mustache. I squirm about it.

It’s also poking me in the homophobia, much like taking ballet did last year. My mustache reminds me a lot more of Freddy Mercury than one of the Beatles. I’m getting over that, though, by watching footage of Queen on Youtube. Freddy Mercury was an incredible rocker.

And anyways I like to push myself in these ways, bust my ego a little, uncover and deal with lingering homophobia, and support a good cause.

Prostate cancer has an amazingly low profile, considering that it’s more common in men than breast cancer is in women. One in six men in the US get it and it kills 30,000 of us a year–more than every other kind except lung cancer. The prostate cancer rates are so high in the elderly that it looks like pretty much every man would get it if they lived long enough. It doesn’t tend to produce symptoms for a long time after it starts growing, so it’s important to get checked after you hit 40. Yes, unfortunately this involves a “digital rectal examination”–a finger in the butt that could save your life. I’ve had one and it’s no fun but it’s not that bad.

Here are the major symptoms according to the Google Health:

  • Urinary hesitancy (delayed or slowed start of urinary stream)
  • Urinary dribbling, especially immediately after urinating
  • Urinary retention
  • Pain with urination
  • Pain with ejaculation
  • Lower back pain
  • Pain with bowel movement

I’m also registered with Movember, so you can donate a few dollars to the cause in my name. The proceeds go to the Prostate Cancer Foundation and LIVESTRONG Young Adult Alliance. Just click here and follow the directions. If my donations add up to $100 or more, I’ll post a photo of the final result in December.

I just went to my first Alcoholics Anonymous meeting. It was the closest one I could find using a Google search–a few blocks from my house, maybe a four minute ride, in a house that I’ve passed hundreds of times. I didn’t expect that. I probably would have guessed that there were something like five or ten AA meetings in all of Eugene and Springfield, but when I searched “Eugene 12-step meetings” I immediately had a list of one hundred and seventy-eight meetings within 15 miles of my zip code. One hundred and thirty-four of those were AA, most of the rest were Narcotics Anonymous, and some were Gamblers (4) and Overeaters (10) Anonymous. They happen every day of the week, from early in the morning until late at night. This movement is huge. No one knows exactly how big because there is no registry, no dues, and the meetings are self-organized, but there were 10 people at my meeting, and this was Halloween night. If 10 is average, that’s something like 1,800 attendees per week, though there is certainly lots of overlap–people attending multiple meetings. Still, that’s a lot of people sitting in a lot of meetings, and that’s in an area with a population of about 200,000.

It was interesting to be so outside of my normal social bubble. I was nervous to go, and nervous when I got there, but everyone was super nice. There were 6 boomers, 2 X-ers (including me), and 2 millenials. I guessed a few were middle class and the rest working class. I’ve been working class my whole life, but these days my social circle is mostly upper-middle, with thin skin and clean hands. My eyes were drawn to the “mechanic hands,” with grease practically tattooed into the grooves of the fingers, and the rough, thick faces of hard lives. We sat in a circle, introduced ourselves, and started reading from Alcoholics Anonymous, the Bible of AA. We each read a paragraph and then passed to the next person. About half of us had what sounded like a grade-school reading level, another reminder of the thin slice of society I live in, so highly educated.

The story was about a rich alcoholic, who failed to get sober in the US and went to Carl Jung in Europe, who also failed to cure him. Apparently, after some effort, Jung told him something like “I have never had any success helping your type of drunk. Sometimes a spontaneous spiritual epiphany can do the trick, and I have been trying to produce that in you, but have failed. You are a hopeless case.”

The format was that anytime anyone felt moved to speak, they would pipe up: “I’m so-and-so, and I’m an alcoholic” and then tell their story or make their comment on the reading. I found it moving to hear their stories and even just to cop to being alcoholics. There was clearly power behind that ability to admit powerlessness. One woman shared about how her life before sobriety was “insanity,” not only in that she was constantly miserable to the point that she felt like her life was “hell,” but in that “What I thought or what I decided about drinking had no impact on whether I drank that day.”

A lot of the readings for my Modern Issues in Addiction class are critiques of the 12-step model, the “disease model,” of addiction. The in-vogue model in post-modern circles like my Couples and Family Therapy program is the “harm-reduction model,” which is secular, so it requires no spiritual epiphany to reorganize the addict’s behavior, and is not aiming at abstinence, but at reducing the damage done by the addiction. One reason harm-reduction is appealing is that you are allowed to count positive outcomes that fall short of abstinence; isn’t it a victory if someone who used to get drunk every night now gets drunk just 3 nights a week? Yes, I think so. Another reason harm-reduction is appealing is that God, even as vaguely defined as it is, is such a dicey topic, hard to manualize for therapy, hard to justify getting behind for us multiculturalists, not wanting to offend the atheists or the theists who have another word for God. The AA God has a male pronoun, for God’s sake. So unhip. It’s hard for us to get behind a program that is not for everyone.

The critiques of the 12-step model have all been theoretical critiques of theory–a form which is quickly becoming my least favorite form of writing. If you have a theory you want to critique, please use data to do so. Please build your counter-theory on data. That would be lovely. The trouble is, the data does not contradict the 12-step model. The summaries of evidence I’ve read (which were written by the critique-ers) basically say that 12-step programs work at least as well as harm-reduction programs, however you measure outcomes, and they work significantly better for addicts who are religious.

The God part of the program was clearly a key part for the folks in my meeting. Two men told harrowing stories about their pre-sobriety days that focused on their denial of their problem. They would go to meetings but they didn’t really “get it” and things got worse and worse. Both described turning-point moments that turned on a prayer. One night, one said in anguish simply, “God, help!” The other said, “Oh, God, I will do anything.” And suddenly they knew that they had a real problem, and that they were personally powerless against it.

I have a difficult time relating to the concept of a second-person God–it’s hard for me to believe anything I can’t directly experience–but I think there is something real and useful going on here. It reminds me of what it’s like to sit in Vipassana meditation. I sit and systematically observe the sensations in my body. It seems as if I have some control over what part of my body I’m focusing on, but I don’t seem to have any control over what sensations I experience in that part of my body. I look and feel what is there, and what is there is given. I am learning to relinquish control over the things that I cannot control. I am practicing not reacting against what is given. And really, how I react is also mostly not in my control, also part of what is given, so I sit with the intention of allowing reality to happen and watch. Suffering is part of the reaction. If I have pain in my body and I react against it, that is suffering. If I have pain and I don’t react against it, that is just pain, which is radically different. And the difference between reacting and not reacting, I think, is grace. It’s my willingness to sit and pay attention, and grace. This is not so different from an alcoholic turning their life over to God. It’s like the serenity prayer, which we said:

God, grant me the serenity
To accept the things I cannot change;
Courage to change the things I can;
And wisdom to know the difference.

When we went around the circle introducing ourselves, each person (just like in the movies) said their first name and that they were an alcoholic. When it came to me I said “Hi, I’m Nathen, and I’m new here.” I was a little nervous about it, but they seemed to like that fine and said “Hi, Nathen!” with just as much enthusiasm as they did for the others.

I’m not an alcoholic. I don’t like alcohol. The first swallow can be pretty interesting, especially if it’s expensive stuff, but after that it starts tasting like something you would scrub your sink out with. I think I inherited that from my mom’s side of the family. That’s how you can tell the Pikes from the in-laws at a family reunion: The in-laws are drinking, the Pikes are not.

I can relate to compulsive behavior, though, mostly around food. And when I say food, I mostly mean sugar. (I seriously considered going to an Overeaters Anonymous meeting for this project instead of AA. I think that I didn’t because I (unfairly, I’m sure) imagined the real food addicts staring at me, maybe hating me in my effortlessly thin body.) At times, I can relate to the woman who said it didn’t matter what she thought or decided about drinking. I can make what feels like a very serious decision not to eat any more cookies today, for example, and then find myself rationalizing my way back to the package. Or ice cream, chocolate, pretty much anything sweet. I can remember sitting, my stomach already feeling kind of bad, looking at a half-eaten bag of chocolate chips, and realizing that I was going to finish those chips. It didn’t matter that I would feel terrible. It didn’t matter that I would have trouble getting to sleep. They weren’t even tasting that good anymore. But I was going to eat them all. I find that disturbing. I think of myself as the kind of person who can and does make decisions and follow through, all the way. That is the kind of behavior psychologists call “ego-dystonic,” or counter to the conception of the self.

So I had my moment of feeling like I was in the right place. It was Halloween night, and they had a big container of candy on a table in the middle of the circle and said, “Help yourself!” It was all crap, in the sense of my intention for this year, “Do not eat crap.” I saw that immediately. I was not hungry, but I wanted some candy. I thought, “I should probably eat a piece or two of that candy to take part in the culture of this group.” I took and ate two Reese’s Peanut Butter Cups–probably my favorite of the crap-class candy–during the meeting. I’m certain no one would have noticed if I hadn’t. My rationalization was just my rationalization. I felt a little guilty for breaking my intention and I noticed my attention going back to the candy throughout the meeting. It was easy not to eat any more, but that may have been because there were no more Reese’s Peanut Butter Cups visible. I would have had to dig noisily through the container while others were reading or sharing.

But while I did have that experience, I don’t mean to make light of the experience of the people at that meeting, or of actual food addicts. I am not a food addict. I have some usually-mild compulsive behavior around food, but not to the point that I’ve ever done anyone wrong or maintained an unhealthy lifestyle. These folks were dealing with something on a whole other level of suffering and trouble. And they seemed to be doing admirably. One man described how when he started craving alcohol, he knew it was time to “reach out”–go to more meetings, call for support, be with good people. As with the others’ sharing, I was moved by his sincerity, conviction, and wisdom.

After an hour of talking, we stood, held hands, and closed with the Lord’s Prayer. I did not expect to be moved by it, but their delivery of the about temptation and evil had such feeling and meaning after hearing their stories:

Our Father who art in heaven,
hallowed be thy name.
Thy kingdom come.
Thy will be done
on earth as it is in heaven.
Give us this day our daily bread,
and forgive us our trespasses,
as we forgive those who trespass against us,
and lead us not into temptation,
but deliver us from evil.
For thine is the kingdom,
the power and the glory,
for ever and ever.
Amen.

Last term I took a class called Wellness and Spirituality Through the Life Cycle. It was a good class. I learned a lot about how people in different spiritual traditions think about and cope with illness, death and dying. It was also depressing. Maybe it was that it came on the heels of Medical Family Therapy, which is another relentless 10-week focus on illness, death and dying. Ten weeks got me down, but 20 weeks had me hitting some pretty strong existential angst: My parents are getting older and are going to die one day. So am I. My grandfather is 91 and doing great but was recently diagnosed with Parkinson’s. Man, am I going to miss him one of these days.

One day in Wellness and Spirituality we had a guest lecturer–Jonathan Stemer, a transpersonal therapist from Looking Glass, the clinic where I now have an internship. He read us a poem from Mary Oliver and a quote from Rilke. Both of them hit home. It’s hard to describe exactly how, but something about the brutality of death and the possibility of an open mind and heart in the face of it. I try to live an open life, but I think that a stance of openness can be an illusion if not in sight of hardships like illness and death. It can be a game of frivolity or superiority – charming but weightless.

“When Death Comes” by Mary Oliver:

When death comes
like the hungry bear in autumn;
when death comes and takes all the bright coins from his purse to buy me, and snaps the purse shut;
when death comes
like the measles-pox;

when death comes
like an iceberg between the shoulder blades,

I want to step through the door full of curiosity, wondering:
what is it going to be like, that cottage of darkness?

And therefore I look upon everything
as a brotherhood and a sisterhood,
and I look upon time as no more than an idea,
and I consider eternity as another possibility,

and I think of each life as a flower, as common
as a field daisy, and as singular,

and each name a comfortable music in the mouth
tending as all music does, toward silence,

and each body a lion of courage, and something
precious to the earth.

When it’s over, I want to say: all my life
I was a bride married to amazement.
I was the bridegroom, taking the world into my arms.

When it is over, I don’t want to wonder
if I have made of my life something particular, and real.
I don’t want to find myself sighing and frightened,
or full of argument.

And here’s the Rilke quote:

“Have patience with everything that remains unsolved in your heart. Try to love the questions themselves, like locked rooms and like books written in a foreign language. Do not now look for the answers. They cannot now be given to you because you could not live them. It is a question of experiencing everything. At present you need to live the question. Perhaps you will gradually, without even noticing it, find yourself experiencing the answer, some distant day.”

Schizophrenia is a fascinating set of phenomena, the study of which has launched a thousand ships including, arguably, my field, family therapy; many of the original family therapists left psychiatry to study schizophrenia (or, as the DSM would have me write it, Schizophrenia–capitalizing words gives them more authority, don’t you think?) as an interactive process. That is, if all behaviors make sense in their context, what context might make schizophrenic behavior necessary?

There was an almost violent backlash against this line of thinking, as it seemed to (and did, in many cases) blame mothers for their schizophrenic children–as in the unfortunate phrase “schizophrenogenic mother.” The conventional wisdom about schizophrenia these days reads like a pharmaceutical company press release, something like, “Schizophrenia is a biological disease of the brain which is at present incurable, but there are drugs which can help manage the symptoms, and if taken regularly can provide a decent quality of life.”

So schizophrenia is assumed to be a biological disease of the brain though it, like every other Mental Disorder, has no laboratory test that can detect its presence. The best we can do is a set of behavioral diagnostic criteria which, frankly, are a bit of a mess. You may notice as you read that different flavors of schizophrenia may have nothing or little in common with each other. Are they really the same “disease”? We don’t know.

We do have good evidence that you can inherit, in some fashion, a tendency for one of these constellations of behaviors. There is good evidence that environmental factors are also important, though they are not a big part of the mainstream discussion. We also have evidence that therapy helps in a lot of cases. There is some (hotly contested, I’m sure) evidence from the World Health Organization that unmedicated schizophrenics can eventually recover while those on medication do not. Here is a trailer for a moving documentary about two recovered women and the public perception of schizophrenia, called Take These Broken Wings. Also, consider checking out the documentary A Brilliant Madness, about John Nash, in which puts the lie to A Brilliant Mind, which showed Nash recovering with the help of psychopharmaceuticals.

The DSM says that schizophrenia may be overdiagnosed (or at least is diagnosed more often) in African- and Asian-American men, that it affects men differently than women (men tend towards the negative symptoms were women tend towards delusions and hallucinations), and that incidence rates are something like .5-1.5% of adults.

Here are a few terms that you’ll need to know to get through the criteria:

affective flattening: does not show emotion. Also, “affect” means “emotion” to scientists and people who like to talk like scientists.

alogia: lack of speech.

avolition: lack of motivation.

prodromal: symptoms coming early on in the course of a disease.

echolalia: repetition of others’ speech sounds.

echopraxia: repetition of others’ movements

And here are the diagnostic criteria, word-for-word, from the DSM-IV-TR, pp. 312-319:

Diagnostic criteria for Schizophrenia

A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

(1) delusions

(2) hallucinations

(3) disorganized speech (e.g. frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior

(5) negative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.

B. Social/occupational dysfunction: For a significatn portion of the time since th onset of the distrubance, one or more major areas of functioning such as work, interpersonal relations, or self-care are mardekly below the level achieved prior to the onset (or when the onset is in childhood or adolewscence, faliure to achieve expected level of interpersonal, academic, or occupational achievement).

C. Duration: Continuou signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. Doring these prodromal or residual periods, the signs of the ditrubance may be manifested by only negative symptoms or two or more symptoms listen in Criterion A pressent in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms):

Episodic With Interepisode Residual Symptoms (episodes are difined by the reemergence of prominent psychotic symptoms); also specify if: With Prominent Negative Symptoms

Episodic With No Interepisode Residual Symptoms

Continuous (prominent psychotic symptoms are present throughout the period of observation); also specify if: With Prominent Negative Symptoms

Single Episode In Partial Remission; also specify if: With Prominent Negative Symptoms

Single Episode In Full Remission

Other or Unspecified Pattern

Diagnostic criteria for 295.30 Paranoid Type

A type of Schizophrenia in which the following criteria are met:

A. Preoccupation with one or more delusions or frequent auditory hallucinations.

B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Diagnostic criteria for 295.10 Disorganized Type

A type of Schizophrenia in which the following criteria are met:

A. All of the following are prominent:

(1) disorganized speech

(2) disorganized behavior

(3) flat or inappropriate affect

B. The criteria are not met for Catatonic Type.

Diagnostic criteria for 295.20 Catatonic Type

A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumptions of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia

Diagnostic criteria for 295.90 Undifferentiated Type

A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.

Diagnostic criteria for 295.60 Residual Type

A type of Schizophrenia in which the following criteria are met:

A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.

B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

I’m learning about child abuse and neglect in my Child and Family Assessment class. Today I read about the ACE study, by the US Center for Disease Control. It is a huge study, with over 17,000 participants, where they gathered information about childhood abuse, neglect, and household dysfunction, and then proceeded to see what health outcomes and behaviors they could predict with that information. It turns out they can predict a lot. They’ve published 50 articles on the study and the research is ongoing–they are continuing to collect health information as the participants in the study age. I’ll present a few of their findings below. For more, see the ACE Study.

Here are some of their findings. I’ll paste in the definitions of the categories of adverse childhood experiences below. Strong correlations were found with the following:

  • alcoholism and alcohol abuse (4 or more categories of ACE meant 4-12 times increase)
  • chronic obstructive pulmonary disease (that is, lung disease)
  • depression (4 or more categories of ACE meant 4-12 times increase)
  • fetal death
  • health-related quality of life (way more inactivity, severe obesity, bone fractures)
  • illicit drug use
  • ischemic heart disease (IHD)
  • liver disease
  • risk for intimate partner violence
  • multiple sexual partners (4 or more categories of ACE correlated with 50 or more sexual partners)
  • sexually transmitted diseases (STDs) (4 or more categories of ACE meant 4-12 times increase)
  • smoking
  • suicide attempts (4 or more categories of ACE meant 4-12 times increase)
  • unintended pregnancies

Here are the kinds of abuse, neglect, and dysfunction they asked about, quoted from the site:

Abuse

Emotional Abuse:
Often or very often a parent or other adult in the household swore at you, insulted you, or put you down and/or sometimes, often or very often acted in a way that made you think that you might be physically hurt.

Physical Abuse:
Sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at you and/or ever hit so hard that you had marks or were injured.

Sexual Abuse:
An adult or person at least 5 years older ever touched or fondled you in a sexual way, and/or had you touch their body in a sexual way, and/or attempted oral, anal, or vaginal intercourse with you and/or actually had oral, anal, or vaginal intercourse with you.

Neglect

Emotional Neglect1

Respondents were asked whether their family made them feel special, loved, and if their family was a source of strength, support, and protection. Emotional neglect was defined using scale scores that represent moderate to extreme exposure on the Emotional Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form.

Physical Neglect1

Respondents were asked whether there was enough to eat, if their parents drinking interfered with their care, if they ever wore dirty clothes, and if there was someone to take them to the doctor. Physical neglect was defined using scale scores that represent moderate to extreme exposure on the Physical Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form constituted physical neglect.

Household Dysfunction

Mother Treated Violently:
Your mother or stepmother was sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her and/or sometimes often, or very often kicked, bitten, hit with a fist, or hit with something hard, and/or ever repeatedly hit over at least a few minutes and/or ever threatened or hurt by a knife or gun.

Household Substance Abuse:
Lived with anyone who was a problem drinker or alcoholic and/or lived with anyone who used street drugs.

Household Mental Illness:
A household member was depressed or mentally ill and/or a household member attempted suicide.

Parental Separation or Divorce:
Parents were ever separated or divorced.

Incarcerated Household Member:
A household member went to prison.

Here’s part 2. (And if you missed it, here’s part 1.) Again, if you are either interested or skeptical, leave me a comment and I’ll point you to the evidence.

Statistically, Divorce is Not a Good Strategy for Getting a Better Marriage: 50 to 67% of first marriages end in divorce. 60 to 77% of second marriages end in divorce.

Your Brain Has Trouble Giving Information About Probabilities Due Weight, So Pay Attention to Base Rates: We have trouble taking the actual prevalence of events into account when making decisions. For example, people tend to be more afraid of dying in a plane crash (lifetime chance: 1 in 20,000) than dying in a car wreck (lifetime chance: 1 in 100) or even of a heart attack (lifetime chance: 1 in 5). One reason for this is that we confuse the ease with which we can think of an example to be an indication of how likely something is. Try this: What do you think is more common, words beginning with “r” or words with “r” as the third letter?

If You Test Positive For a Very Rare Disease, You Still Probably Do Not Have That Disease: This is a headline that should come from medicine, not psychology, but psychologists are better at probability than doctors, who are no better than laypeople, at least when it comes to thinking about this: Even with a very accurate test, if a disease is very rare, a positive result is still much more likely to be a false positive than an accurate positive. I’m going to explain this, but if you don’t get it, don’t worry. Just remember the headline. It’s true.

The table below shows a hypothetical situation with super-round numbers to make it easier to get. You have gotten positive results on a test that is 99% accurate for a disease that occurs only once in 10,000 people. Most people figure they are 99% likely to have the disease. They are wrong:

Test Results
Disease Present? Test Results Positive Test Results Negative Row Totals
Disease Present 99 1 100
Disease Not Present 9,999 989,901 999,900
Column Totals 10,098 989,902 1,000,000

Since your test results are positive, you are somewhere in the left-hand column. You are either one of the 99 who both have the disease and whose test results are positive, called “hits,” or one of the 9,999 who do not have the disease but whose test results are positive, called “false positives.” As you may see, even though your test results are positive, you still are 99% likely to be a false positive and not a hit, simply because the disease is so rare.

Yes, this is counter-intuitive. That’s why it’s important. And that’s why statistics are important. Again, if you don’t understand, don’t worry. If you don’t believe it, though, come up with a specific question, leave it as a comment, and I’ll answer it.

If You Need Help, Ask Someone Specific for Something Specific: Bystanders generally do not help people who are in trouble. The bigger the crowd, the less likely someone will help. It’s not because they are bad or lazy. It’s a specific kind of well-documented confusion. Kind of like in the clip below. What you need to know is, if you need help, even if it seems like it should be completely obvious to anyone around, like you’re having a heart attack, falling to the ground, gasping, whatever, point to a specific person and give them specific instructions: “You, in the red shirt. I’m having a heart attack. Call an ambulance.” Do not assume anything will happen that you did not specifically ask for. A corollary of this headline is, if you think someone might be in trouble, don’t assume they would ask you for help, and don’t assume someone else is helping them. Help them yourself. It could mean the difference between them living or dying.

Get Help For Your Marriage When the Trouble Starts (Or Before): On average, couples wait 6 years after their marriage is in trouble to get help. The average marriages last 7 years. That means that most people who come to couples counseling are deeply entrenched in problems that would have been relatively easy to resolve earlier. It is not uncommon for a couple to come in to counseling with a covert agenda to use the counselor to make their inevitable divorce easier. We can do this, but believe me we’d much rather meet you earlier and help you stay together! Also, I’m not joking about “or before.” Couples counselors are well-trained to give “tune-ups” to couples who are doing well. It’s a good idea.

Anger Is Not Destructive of Relationships, Contempt and Defensiveness Are: Everybody argues. Everybody screws up their communications. It’s the ability to repair things that is the key, and contempt and defensiveness get in the way of that.