(By Lindsay Beller)

Sometimes it is easy to deduce what led someone to commit a crime. Take the woman who, traumatized by prior sexual assault, severely reacts to an unwanted advance and finds herself charged with attempted murder. Or the man who was raised in an abusive home and is later arrested for beating his own children. In other cases, the reasons are much less clear. Why does a successful executive, who makes a good paycheck and leads a happy life, risk it all by committing a white-collar crime? How does a person from a lawabiding family grow up to shock his neighbors and loved ones when it is discovered that he is the serial killer who has been terrorizing his community? Did something happen earlier in these people’s lives that we simply don’t know about, or are their brains hardwired for criminal activity?

The causes of criminal behavior have long been up for debate, and today there are still more questions than answers. Are criminals born prone to a life of aggression and anti-social behavior? Are they products of their environment? Is it a combination of both nature and nurture? Research indicates that genetics is responsible for about 50 percent of criminal behavior and that environment accounts for the rest. Many experts argue that inheriting a particular gene doesn’t necessarily predispose someone to a life of crime—but add in an abusive or violent childhood or another negative environmental factor and that risk greatly increases.

What Role Does Environment Play?

Complicating the equation is the notion that while many of those charged with criminal acts share a common set of personality and behavioral traits— such as impulsivity and the need for immediate gratification—the wide range of offenders and offenses makes generalization difficult. Ask Dr. Michael Fogel what causes criminal behavior and his answer is, “It depends.”

“There is no 100 percent certainty that an individual who possesses certain characteristics will engage in a crime. Life gets in the way,” said Dr. Fogel, associate professor of forensic psychology at The Chicago School’s Chicago Campus. “When you understand where the individual came from, what they were exposed to, and the environment in which they grew up, you can understand why they engaged in the behavior that they did.”

Many experts argue that inheriting a particular gene doesn’t necessarily predispose someone to a life of crime—but add in an abusive or violent childhood or another negative environmental factor and that risk greatly increases.

Researchers have long studied the idea that the nurturing an individual does or doesn’t receive influences behavioral development, and found environmental factors such as coercive parenting styles, physical and sexual abuse, neglect, and family conflict are related to antisocial behavior. For example, research has shown that trauma during childhood can lead to aggressive or even criminal behavior. Dr. Kendell Coker, assistant professor of forensic psychology at The Chicago School, has conducted research on the relationship between trauma and delinquent behavior among inner-city minority youth. In one study that explored the association between these two concepts, he found youth who are exposed to more trauma have poorer social problem-solving skills, which in turn is related to higher delinquency.

“Trauma has been shown to have a large impact on youth, and it can also lead to criminal behavior, but not because the kid all of a sudden sees something bad and they go bad,” Dr. Coker said. “It’s because they start to see the world as a hostile place and their source of protection wasn’t there when they needed it, so they feel like they need to protect themselves. A lot of juvenile misconduct happens in social situations. Juveniles are more susceptible to peer pressure and they don’t think about the consequences of their actions.”

In an effort to understand the extent to which both environment and genetics impact antisocial behavior, numerous twin and adoption studies have looked at the traits and personalities of identical and fraternal twins raised in the same and separate environments (identical twins share all of their genes while fraternal twins share 50 percent of them).

Studies also looked at adoptees, and whether they exhibited similar traits to their adopted parents. Results have varied. Some research found evidence that genetics determined antisocial behavior while other studies concluded environmental factors played a stronger role. Still other research has found that an interaction between genes and environment predicts criminal behavior.

British psychologist Francis Galton initiated the first twin studies in the late 19th century. Considered a pioneer of behavioral genetics, Galton’s research led to the exploration of the nature vs. nurture debate. His interest in heredity was inspired by his cousin Charles Darwin’s book about evolution, The Origin of Species, as well as his belief that intelligence and other “human mental abilities and personality traits” were passed down through heredity. His ideas represented the beginnings of the eugenics movement, which aimed to remove “undesirable” people from the gene pool—a movement that gained popularity in the United States in the early 20th century, but ultimately hindered research into the links between biology and criminal behavior.

Are Genetics to Blame?

Spurred in part by racist attitudes toward large waves of immigrants arriving from Asia and Southern and Eastern Europe, eugenics researchers believed if they could control which human genes were passed on, they could eradicate conditions and traits including mental retardation and learning disabilities (or “feeblemindedness,” as it was called), physical disabilities, criminality, epilepsy, and alcoholism, which were considered a drain on public resources. At the time, a limited scientific understanding of heredity was based on research of dominant and recessive genes in plants, and the notion that if animal breeders could select desirable traits for their livestock, the same idea could apply to humans. The Eugenics Record Office was founded to compile genetic information from families, but the data was ambiguous and collected by many individuals who had their own prejudices about what made someone fit to reproduce. While no scientific data confirmed the heritability of most traits, there was widespread support for the movement that led to institutionalization policies and forced sterilization laws. In 1907, Indiana became the first of 30 states to legalize involuntary sterilization. Although the eugenics movement was scientifically discredited after revelations of Nazi experiments on Jews, Gypsies, homosexuals, and other groups during World War II, the last state law was not repealed until 1981. In that time, estimates of up to 70,000 men and women underwent forced sterilizations and thousands were institutionalized against their will.

Despite the declining credibility of eugenics, researchers continued efforts to link biology and criminality, and some unethical research practices persisted in the 1960s and 1970s. For example, the “Supermale” syndrome posited that men with an XYY chromosome pattern were thought to exhibit aggressive and antisocial behavior. Although subsequent research invalidated this idea, many newborns, juvenile delinquents, and prisoners were screened for the extra chromosome without consent, leading to further stigmatization for a condition that ultimately had no scientific basis.

But since the completion of the Human Genome Project in 2003, which identified thousands of new genes, there has been a renewed, yet cautious, interest in the link between biology and criminal behavior, and the research has only recently begun to gain a fragile credibility. Certain genes, like one that regulates the production of the MAOA enzyme, for example, have been linked to aggressive and impulsive behavior. But while about 100 studies have shown a link between genes and crime, many researchers reject the theory of biological determinism—that our genes determine our personalities and who we become—and say that environment plays an important role in whether and how a gene is expressed.

Our Brains and the Law

The brain has become the latest frontier in the quest to understand criminal behavior, particularly of psychopaths and violent offenders. In the growing field of neurocriminology, which is the application of neuroscience to criminology, researchers have documented differences between the criminal brain and the “normal” brain.

Dr. Adrian Raine, a psychologist at University of Pennsylvania, has conducted studies that show a correlation between criminal behavior and the amygdala—“ the guardian angel of behavior” as he described it to an audience at the University of Missouri. The amygdala is located in the prefrontal cortex and is associated with emotion and fear—the idea being the less fear someone has, the less likely he is to have a conscience guide his behavior. In one study, he found an 18 percent volume reduction in the amygdala of psychopaths compared to non-psychopaths.

Dr. Raine was also part of a longitudinal study that examined the fear-conditioning response of 3-year-olds in the island nation of Mauritius. Based on the theory that a dysfunctional amygdala leads to poor fear conditioning and increases the risk of criminal behavior, his team examined children early in life and, 20 years later, gathered information on whether they committed crimes as adults. To measure their level of anticipatory fear, the children wore headphones and listened to a neutral sound followed a few seconds later by a harsh noise. This was repeated several times, so the children knew that the unpleasant sound would always follow the first one. If the child’s “sweat rate” increased while anticipating the second noise, this suggested a normally functioning amygdala. The follow-up study revealed that many of the children who had not shown anticipatory fear during that test had become convicted criminals. Despite his observation that “bad brains lead to bad behavior,” Dr. Raine shares the belief with many other researchers that one’s environment can still impact whether someone becomes a criminal. “It’s not biology versus environment. It’s biology plus environment,” he told The Times of London in a 2010 interview.

At least one psychologist rejects the notions that biology or environment leads to criminal behavior. In his book, Inside the Criminal Mind, Dr. Stanton E. Samenow argued that regardless of their background, criminals think differently than non-criminals—that they make a choice to commit a crime, and should be held fully responsible for their actions.

Blaming one’s environment or even a mental illness paints the offender as a victim, he writes, and research on genetic links to criminality has been inconclusive. Instead criminal patterns such as lying and breaking rules begin during early childhood and culminate into a life of crime. “The person who makes crime a way of life has a radically different way of thinking from the individual who behaves responsibly,” he wrote in the book. “The two mentalities are so different, it’s as though the criminals were a different breed.”

Based on this theory, Dr. Samenow—who collaborated with and built on work started by his mentor, Dr. Samuel Yochelson, in the 1960s—proposed that the only way to rehabilitate a criminal was for him to change the way he thinks, which would lead to better behavior. In their 1977 book The Criminal Personality, the authors identified 52 “thinking errors,” such as poor decision making, failure to consider injury to others, and lack of trust. The notion that criminals demonstrate errors in their thinking has become a critical element in cognitive behavior therapy (CBT), which is considered the most effective treatment to keep offenders from committing further crimes.

What Treatments Work?

Advances in treating offenders have come a long way since 1974 when sociologist Robert Martinson reviewed 231 studies that evaluated the impact of rehabilitation programs and found they had little impact on recidivism. The media seized on the message that “nothing works,” repudiating the criminal justice system’s focus on the rehabilitation of criminals. The findings, splashed on magazine covers and in newspaper articles, contributed to the rise to the “get tough on crime” approach in the United States.

Cognitive behavioral therapy emerged as the treatment with the greatest impact in reducing the recurrence of criminal behavior in juveniles and adults.

But in the decades that followed, even as the criminal justice system became more punitive, cognitive behavioral therapy emerged as the treatment with the greatest impact in reducing the recurrence of criminal behavior in juveniles and adults, and in decreasing the incidence of depression and substance abuse. One 2005 study found that CBT reduced recidivism by an average of 25 percent, with some programs finding reductions of more than 50 percent. Even high-risk offenders were responsive to the treatment.

Changing the Way We Think

CBT—a blend of cognitive theory and its focus on internal thought processes with behavioral theory and its emphasis on external behaviors—teaches offenders to identify distortions in their thinking and understand that altering the way they think will lead to positive changes in behavior. Offenders might be taught coping or problem-solving skills. Dr. Nancy Zarse, associate professor of forensic psychology at The Chicago School, explained how the treatment worked for an inmate she treated during a 16-week cognitive behavioral therapy program. When asked to describe the crime that he had committed—from start to finish—the offender told of a midnight visit from an acquaintance inviting him to help steal $800 tires from a car that had broken down.

“We walked through, from that moment on, how many thinking errors he had and how many rationalizations there were between him leaving that house and getting to the actual car,” she said. “Part of what I wanted to help him see was at how many different points he could have made a different choice and not gone to the crime scene. Because once you’re there, what’s the likelihood that you’re going to turn away?”

When the program concluded, the inmate told her that the exercise was the most valuable part of his treatment. “For him, that’s when he realized, wow, that’s what I’ve been doing,” Dr. Zarse said. “Part of what you want to teach in cognitive behavioral treatment is those earlier decisions, those earlier thinking errors and cognitive distortions, that have a pro-criminal influence as opposed to a pro-social influence.”

Other treatments such as behavioral therapy and psychotherapy show little evidence of being as effective as cognitive behavioral therapy in treating criminals. One study that found that CBT programs were 30 percent more effective than behavioral ones, while a

2007 report from the National Institute of Corrections stated, “Traditional psychotherapy is egocentric; it helps individuals solve their personal problems, feel better about themselves, and fulfill their inner goals and expectations. This egocentric psychotherapy, in and of itself, has failed to have significant impact on changing the thinking, attitudes, and behaviors of offenders.”

As CBT became the widely accepted treatment for offenders, an evolution in risk assessments has resulted in more accurate evaluations and treatment plans. At first professional judgment was used to predict criminal behavior until the 1970s, when psychologists recognized that risk assessments needed to more evidence behind them. They began to consider such factors as the history of criminality, substance abuse, past employment, violent behavior, social networks, and age, which improved accuracy and credibility. Assessments further evolved to consider factors like the offender’s current situation resulting in more targeted interventions. In the last few years, a supervision component has helped ensure that offenders are compliant with their treatment, which reduces their risk of further criminal behavior.

As risk assessments improved, psychologists D.A. Andrews and James Bonta developed the risk-need-responsivity (RNR) model of offender rehabilitation. First used in Canada, the model is considered the most effective way to assess and treat criminals, especially higher-risk offenders who traditionally weren’t as likely to receive rehabilitation services as low-risk offenders. The RNR model is based on three principles that guide interventions: the offender’s level of risk, the services that address criminogenic needs, and the types of treatment programs to provide.

Providing interventions that target the offender’s criminogenic needs is considered critical to overall success. As opposed to static risk factors linked to criminal behavior, such as one’s history of violence, criminogenic needs are dynamic risk factors that can be altered to bring about more positive outcomes. For example, if all of an offender’s friends are criminals, a treatment program would encourage him to avoid bad influences. Or if the offender has too much time on his hands—time that typically gets him into trouble—a treatment program might introduce a new activity and support participation.

Although research is producing evidence-based treatments that have a positive impact on recidivism, such advances alone often aren’t enough to magically turn prior offenders into law-abiding citizens. Such programs cost money to implement, and lack of funding is an ever-present impediment. In 2009, there were more than 1.6 million incarcerated in state or federal prisons, according to the Bureau of Justice Statistics, but the recession has led to budget cuts in rehabilitation programs. Last year, California cut 36 percent in funding for such initiatives, and numerous other states have made or are considering cuts, including Texas, Kansas, Indiana, and Pennsylvania. “Psychological factors play significant roles in criminal behavior, but it takes time to treat them, and oftentimes there aren’t resources to do so,” Dr. Fogel said. “How much rehabilitation can occur when there isn’t money provided for programs?”

{by Doug McInnis and Judy Beaupre}

When Joan was diagnosed with isolated systolic hypertension—a condition that affects more than 10 million Americans over the age of 65 each year—the treatment plan seemed obvious enough. With dozens of blood pressure medications on the market, it was just a matter of finding the one that worked best for her.

The answer, however, wasn’t so simple. On a regimen of two drugs, the 68-year-old patient found herself battling headac hes, dizziness, fatigue, and frequent coughing spells—yet her blood pressure readings still registered high. So her doctor, Herbert Benson of Harvard Medical School, tried a different approach entirely: He sent her home with a compact disc—loaded with soothing voices and sounds—and instructions to listen to it daily while visualizing calming scenes.

Eight weeks later, Joan’s blood pressure was normal.

Joan became a case study in how the effective mind-body treatment of hypertension can result in the complete elimination of anti-hypertensive drugs,” Dr. Benson writes in his book, The Relaxation Revolution: Enhancing Your Personal Health Through the Science and Genetics of Mind Body Healing, published in June 2010. Dr. Benson’s research dates back more than 35 years (his first book, The Relaxation Response, was published in 1975), qualifying him as a pioneer in incorporating mind-body approaches into Western medicine.

Dr. Benson is far from alone in his thinking or research however. In 1994, Dr. Andrew Weil, a Harvard-trained physician and professor of medicine, founded the Center for Integrative Medicine at the University of Arizona, the first program that formally trained physicians in incorporating mind-body approaches into their practices. Other institutions followed his lead, including Harvard, Johns Hopkins, Duke, UCLA, and Georgetown. Today more than one-fifth of U.S. medical schools are members of the Consortium of Academic Health Centers for Integrative Medicine.

“My intent in founding the center was to train physicians in a new way of thinking about medicine to cover the areas of deficiency in conventional medical education.” Dr. Weil says. In his book, Natural Health, Natural Medicine: The Complete Guide to Wellness and Self-Care for Optimum Health, he explains what he feels those deficiencies are.

Mind-Body Milestones

“Mainstream medicine continues to be the same as it has been, but more so: more expensive, more reliant on technology, more focused on the physical body to the exclusion of mind and spirit.” In an increasing number of treatment settings, mind-body approaches are being integrated into traditional Western medical practices. They include psychological counseling, mindfulness exercises such as meditation and yoga, nutrition management, massage therapy, and herbal remedies. Facilities such as the Center for Mind-Body Medicine in Washington, D.C., founded by another physician—Dr. James S. Gordon—are springing up in metropolitan areas across the country.

And while a small but growing number of mainstream medical school programs are incorporating alternative approaches into their curriculum, a handful of specialized institutions such as Santa Barbara Graduate Institute (SBGI) have been established specifically to address the need for a more integrative type of health care.

“The connection between mind and body and our overall health is difficult to ignore,” says Dr. Marti Glenn, who founded SBGI a decade ago and today serves as its campus dean. “Our attitudes and emotions affect us on a cellular level, and become evident in conditions that range from ulcers and high blood pressure to chronic pain. Many research studies have compared patients who suffer from the same malady but have different psychological experiences; their outcomes are very different.”

SBGI currently offers programs in somatic, prenatal, and perinatal psychology, and has plans to infuse its holistic philosophy into professions such as nursing, occupational therapy, and physical therapy. “We can’t just treat the symptom, we have to treat the human being,” Dr. Glenn says. “Healing and resiliency are affected by so many factors: lifestyle, resources, values, developmental history, and emotional health.”

A Solid Research Base

Research is producing mounting evidence linking physical health to mental or emotional health. Both the medical and psychological communities acknowledge that issues such as stress, anxiety, depression, and anger—once believed to impact only one’s emotional well-being—must be addressed to effectively deal with conditions ranging from diabetes to heart disease to cancer. The American Psychological Association has compiled more than 300 studies that show that stress weakens the immune system, and that proactive psychological interventions can work hand in hand with front-line medical procedures in curing or slowing disease. In just one example, women treated for breast cancer were 56 percent less likely to die from the disease if they participated in group therapy sessions than if they did not.

In September 2010, researchers attending a heart-brain conference organized by the Cleveland Clinic reported on more than 100 studies linking depression and stress to cardiovascular disease. Dr. Marc Penn, a cardiologist at the Cleveland Clinic and director of the clinic’s Heart-Brain Institute explains the connection.

Depression is believed to impact the operation of the body’s vagus nerve in ways that increase inflammation that can damage the heart, he says, adding that the situation is made even worse by the fact that depressed patients often ignore treatment protocols and lead sedentary lifestyles.

Acknowledging that depression treatment is an inexact science, Dr. Penn points to a wide range of treatment options that include psychological counseling, drugs, exercise, and relaxation therapy. While all approaches work, he says, they don’t all work for everyone. “It all comes down to whatever works for the patient,” he says.

Holistic Approaches Across The Country

Dr. Benson, who is an associate professor at Harvard Medical School and the director emeritus of the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital, uses his relaxation protocols for a far wider range of illnesses than the hypertension his patient Joan experienced. His approach is used in the treatment of heart disease, cancer, HIV, depression, and diabetes. The latter two often go hand in hand. The University of Washington School of Medicine and Seattle’s Group Health Research Institute recently collaborated on a study of patients with diabetes and
found they were more likely to suffer potentially life-threatening complications from their illness if they were depressed.

“Diabetes patients require four to five medications to control the disease, and many need more than that,” says Dr. Elizabeth Lin, a Group Health researcher who took part in the study. “When patients are depressed, they may not take their insulin on time or at all. They are also more likely to eat badly, smoke, and exercise less. These factors all contribute to what we saw in our study.”

Dr. Sandra Siegel, an addictions specialist and associate professor of clinical counseling at The Chicago School, agrees. “We’re seeing this huge number of people with Type 2 diabetes because of overeating,” she says. “If we just put them on a diet and don’t deal with what’s fueling the behavior, we won’t see much improvement. When I teach, I recommend looking at the patient holistically.”

The holistic approach that Dr. Siegel recommends is used at some medical centers, including Chicago’s Mount Sinai Hospital, which offers psychological counseling to ill children and teens through its pediatric and adolescent behavioral health program, Under The Rainbow. “If a 16-year-old diabetic is seen by one of our doctors, we then work with the kid to explain that this disease is something that will be with them the rest of their life,” says Dr. Richard Macur-Brousil (Psy.D.’91), the program’s director and an alumnus of The Chicago School’s Clinical Psychology program. “But we also tell them that they can control it with diet, behavior, and insulin.”

The psychological staff works with parents as well,  he adds, because coping with diabetes is a family affair. Parents are encouraged to change family menus to conform to their child’s dietary restrictions. For the diabetic, eating the wrong food can lead to diabetic comas, or to the chronic diseases the diabetes can cause—heart disease and kidney failure among them.

“If the family eats the same meal, it’s very helpful,” says Dr. Macur-Brousil. “But if the family eats one thing and the kid eats something else, then he will fall off the wagon.”

Despite the efforts of believers like Drs. Benson and Weil and the example set by the doctors at Mount Sinai, however, prescription drugs and the surgeon’s scalpel still dominate American medicine. Much of the reason lies with the patients themselves, who often prefer a quick fix. “Whatever the problem, the first intervention in Western medicine is a pill,” says The Chicago School’s Dr. Siegel. “Western medicine doesn’t stop to look at the whole person and what’s fueling the problem.”

Why do so many doctors take the single-minded approach that Dr. Siegel describes? Because physicians are trained primarily in medical interventions—surgery and prescription drugs—many don’t have the experience that psychology and counseling professionals have in incorporating behavioral interventions. Even when they are aware of the benefits of a holistic approach, doctors lack both the training and time to diagnose psychological issues or help their patients reverse unhealthy lifestyles. Studies show that doctors spend an average of 20 minutes with a patient per visit—hardly time to unravel the emotional tangles that often underlie the patient’s physical complaints. Nor are they equipped to deal with hurdles faced when trying to treat a patient who is in denial about his disease.

“A doctor may say ‘You’re not taking your medicine. Take it!’” says Dr. Cynthia Langtiw (Psy.D.’05), a former Mount Sinai psychologist and an assistant professor of clinical counseling at The Chicago School. “And the kid says ‘sure’ and then goes back to what he’s doing. Doctors just don’t have time to deal with this. It would involve assessing the patient and finding ways to motivate him to deal with a disease that doesn’t go away.”

A Long Way To Go
Despite the growing evidence that many patients can benefit from—and often require—a treatment regimen that goes beyond conventional medicine, health care that targets both mind and body remains the exception rather than the rule. “Mind-body science has now reached a stage where it should be accepted as the third major treatment and prevention option, standing as an equal alongside drugs and surgery,” says Dr. Benson. “If we could lower the incidence of disease through effective preventive medicine and also cut costs with less expensive mind-body approaches, we might save hundreds of billions of dollars now spent or lost through excessive medications, stress related diseases, and lost work days.”

By the Numbers

Among psychologists, the holistic approach has gained traction. It is mental health practitioners, after all, who are frequently called in to pick up the pieces of shattered lives, and what they find is a web of physical and emotional ills that feed on one another. If addressed earlier in a primary health setting, psychology and counseling professionals argue, the human and financial savings could be huge.

But changing the existing system would be a tall order. Government data show that, in its current form, American medicine is a $2 trillion-a-year industry that supports more than 14 million jobs. An integrated care model could shake up this system by substituting inexpensive alternative care for more costly traditional drugs and procedures. “When a patient has learned the basic techniques for applying mind-body approaches in medical treatment and prevention, the techniques cost nothing to administer,” Dr. Benson says in his book. “The use of mind-body medicine will decrease the overall use of medical services, and, concomitantly, reduce medical costs.”

As an example, he cites one study showing a 43 percent reduction in doctor visits by arthritis patients who participated in a self-management program, and a 20 to 36 percent decline in costs for patients who underwent brief psychotherapy treatments for six to 12 months. “Those Medicaid patients who spent the most time in counseling tended to have the highest percentage reduction in their medical costs,” Dr. Benson writes.

Because most health care in the United States is not approached holistically, the burden of balancing medical treatment with psychological counseling often falls to the patient. Mental health intervention adds another entire layer—of appointments, cost, and insurance considerations. In the long term, psychological intervention saves money by heading off medical crises, says Dr. Macur-Brousil. For instance, when a young diabetic crashes, he will typically go to the emergency room, where the average charge is $400. Then he will be hospitalized for three to six days at an average cost of $500 a day. (These costs reflect typical charges at Mount Sinai, which treats indigent patients, Dr. Macur-Brousil explains; many hospitals charge significantly more). “We can avert these hospitalizations with weekly cognitive-behavioral therapy for two or three months at a monthly cost of about $280,” he adds.

The potential savings goes far beyond dollars and cents though—they also can be counted in terms of avoiding complications such as blindness and heart disease. But before any savings materialize, chronically ill patients must first have access to mental health care. Congress moved to increase access in 2008 when it voted to require parity between medical and mental health coverage in health insurance plans. Yet, even with this legislation now enacted, psychological care is still elusive for many Americans, 50 million of whom are without health insurance. Millions more are underinsured; although they may have insurance, large deductibles and co-pays limit their willingness and/or ability to seek treatment for any but the most pressing—usually physical—problems. Still others may avoid seeking help, even when it’s both available and affordable, because they believe psychological counseling carries a stigma.

In the meantime, vast sums are spent on treatments that cost too much and may not work. “We spend at least $15 billion per yearon medications for insomnia alone, which do not work well over the long term and which can often be replaced by mind-body interventions,” says Benson. “The huge amounts of money at stake in medical care must not be minimized,” he contends. “(It’s) a sum that represents almost one-fifth of the American economy. Imagine the savings that we may achieve as we begin to take the mind-body option more seriously.”

By Judy Beaupre

Long misunderstood, too often ignored, and repeatedly misdiagnosed, it has gone by a multitude of names. World War II veterans struggled with the symptoms of “battle fatigue,” while their fathers and uncles spoke in whispers of “shell shock,” the mysterious malady that for many defined the months—even years—following the First World War. And five decades before, men in Confederate grey and Union blue returned from the bloodiest war in American history, forever burdened with memories of death and devastation, an enigmatic syndrome that became known as “soldier’s heart.”
It was not until the Vietnam War that post-traumatic stress disorder (PTSD) began gaining recognition as the real and debilitating affliction it is. No longer dismissed as an indicator of personal weakness, cowardice, or damaged nerves, PTSD captured the attention of the mental health community—making its way into the third edition of the Diagnostic and Statistical Manual in 1980. Not far behind came the attention of the media, the Pentagon, and the public at large.

“It’s taken us a long time to recognize that an elevated level of stress as a result of combat is really the norm,” says U.S. Navy Commander John Ralph, director of mental health services for the National Naval Medical Center in Bethesda, Md. “It is universal; no one can deploy and not experience it. Our focus now is to distinguish temporary stress from PTSD and to let troops know that it’s important to deal with.”

Today, some seven years into the Afghanistan and Iraq wars, the prevalence of post-combat psychological and cognitive problems has reached unprecedented levels, sounded new alarms within the military and veterans’ communities, and led to a myriad of initiatives designed to understand, diagnose, and heal these invisible wounds of war. A 2008 study by the Rand Center for Military Health Policy Research estimated that 20 percent (more than 300,000) of soldiers returning from Middle East deployments had met the screening criteria for PTSD and/or major depression, and that 320,000 had experienced a probable traumatic brain injury (TBI). Overall, Rand speculated, one in three U.S. servicemen and women were returning from combat duties with significant psychological problems. Worse, only half had sought or received treatment for their injuries.

It took years to realize that the cumulative impact of treating those who had experienced the horror firsthand could be just as traumatizing.

As the longest-running wars fought by an all-volunteer United States military, the current conflicts have resulted in the deployment of almost 2 million troops and, for many, prolonged and repeated periods of combat-related stress or traumatic events. Evidence gathered by the Rand Center suggests that the psychological toll of the deployments may be disproportionately high compared with physical injuries.

“We found that the single biggest risk factor for PTSD and major depression was exposure to trauma,” said Terri Tanielian, co-director of the study. “The more exposures a soldier experienced, regardless of number or length of deployments, the more likely he was to return home with psychological problems requiring treatment.”

The study identified 23 experiences—including 11 that were rated highly predictive—that contribute most often to post-combat anxiety and depression. They range from engaging in hand-to-hand combat to having a friend killed to being responsible for the death of a civilian. The study represented the first large-scale nongovernmental assessment of the psychological and cognitive needs of troops serving in Iraq and Afghanistan and representing all branches of the armed forces.

Robert Diosdado, who served as a platoon leader and brigade training officer, and more recently, as a civilian organizational consultant to the U.S. Army, believes direct combat exposure is not a required determinant of PTSD. Different kinds of wars call for different definitions of trauma, he says, and today’s typical combat tour is characterized by “months of boredom, followed by a few moments of sheer terror and chaos.

“There are no front lines in Iraq and Afghanistan, which has changed the combat dynamic,” says Diosdado, who, from his post in Afghanistan, is pursuing a Ph.D. in Organizational Leadership at The Chicago School of Professional Psychology in an effort to integrate psychological theory into the work he currently does for the Army. Because all troops deployed to these countries work under a constant threat of mortar attacks, suicide bombers, or encountering improvised explosive devices (IEDs), the projected threat is often far worse than the actual event, he explains. “The fear of being attacked is almost unbearable for some people. I’ve seen soldiers attempt to substantiate their continued fears by creating a reality in which they were actually involved in combat.”

Taking action

The upside is that the military has taken huge strides in understanding and treating the PTSD and/or major depression that so often accompany deployment to a battle zone. While diagnoses of these conditions far exceed those of previous wars, military mental health professionals readily acknowledge that the trend can be attributed in part to their increased capacity to recognize and address the symptoms than ever before in history.

Since Civil War days (when mustered soldiers bearing obvious symptoms of what today would be diagnosed as PTSD were put on trains home with only the name of their hometown pinned to their uniform) and early 20th century wars (when mental health professionals were used primarily for intelligence and “sanity” testing of recruits), the military has made steady progress in its incorporation of psychology into wartime healthcare strategies.

It was during the 1960s and 1970s—as the war in Vietnam was escalating—that an understanding of combat-related trauma was beginning to take hold, psychology professionals agree. But while the problem was gaining acceptance, it would be years before evidence-based treatments were available to provide the early and aggressive therapy that is often recommended as a result of today’s post-deployment screening.

“Back in Vietnam, a soldier had to be involved in something horrific to even be considered for a diagnosis of PTSD,” says Dr. Larry James, a clinical psychologist and retired Army colonel who directed mental health services at both Walter Reed and Tripler Army Medical Centers during his 22-year military career. “It took years to realize that the cumulative impact of treating those who had experienced the horror firsthand could be just as traumatizing and require similar levels of therapy.”

Further complicating the mental health environment of that era was the fact that troops were returning from an unpopular war to homecomings that were often anything but welcoming. While the previous generation had returned from World War II and Korea heralded as heroes, Vietnam veterans “were afraid to wear their uniforms through the airport for fear of being spit upon,” says Dr. James, who is now president of the American Psychological Association’s Society for Military Psychology (Division 19) and dean of the Wright State University School of Professional Psychology. “This just added to the stress and depression that many had experienced during their months in Southeast Asia.”

But gradually times have changed. Today initiatives taken by all service branches, as well as the Departments of Defense and Veterans Affairs, have dramatically altered the ways in which troops are assessed and treated during all phases of deployment and its aftermath. Dr. Ralph points to the Navy’s decision 15 years ago to begin putting clinical psychologists on every aircraft carrier.

“This represents a total change in the outlook of the Navy at large,” he says. “Commanding officers used to have to make the difficult and expensive decision to send sailors with psychological problems off the ship, but we have gotten that number down to almost zero. Psychologists are now on board and available to help sailors talk through problems and resolve personal issues. It’s a very different model for us.”
The Navy also provides medical services for the Marine Corps, which for the first time in the coming fiscal year will embed clinical psychologists in units serving in Iraq and Afghanistan.

“Before, psychologists were primarily attached to hospitals. It made the whole idea of mental health more mysterious and much more prone to stigma,” says Dr. Eric Getka, national training director for navy psychology. “By having them available to marines in the field and as an actual part of their unit, we’ve come a long way in dispelling the myths around mental health care.”

Dr. Ralph attributes changes in the healthcare focus of the Navy to a combination of compassion and pragmatism on the part of senior officers. It’s the right thing to do for our men and women in uniform, he says, but it also reflects officers’ sense of responsibility to doing their jobs well.
“Officers need to make sure their men are ready to fight. They have to be attuned to anything that could degrade that readiness,” he says. “Losing people to mental health problems has an adverse effect on everyone involved.”

Now we have crusty generals talking about their own issues to troops. I can remember a time when no admiral or general would ever admit to having problems like that.

The Army, too, has increased its focus on the mental health of its troops. In collaboration with the University of Pennsylvania, it offers a pilot program in master resilience training as part of a newly launched Comprehensive Soldier Fitness program, which prepares troops for the physical and psychological challenges of sustained operations. Army Chief of Staff Gen. George Casey recently pinned his hopes on the new fitness program as a means of reducing the continuing rise in suicides in the Army.

“We’ve increased by about 18 suicides a year since 2004 and this past year, after all the effort we made, we increased by another 20,” he told the Senate Appropriations defense subcommittee in March. “I’m personally frustrated that we haven’t stemmed the tide.”

Fighting Stigma

Despite the proactive stance that the military is taking toward the psychological health of its troops, however, barriers that are hard to overcome remain. Stigma is still a central issue, even as the armed services struggle to convey the message that combat stress is universal, inevitable, and not necessarily an indication of disorder. A big deterrent to coming forward for screening or treatment, they say, is the fear of sabotaging their careers, forfeiting the next promotion, or losing their security clearance. A big step forward was taken in 2008 when a Defense Department policy was revised to allow a way around what U.S. Defense Secretary Robert Gates called “the infamous Question 21.”

Question 21—long a standard part of the Questionnaire for National Security Positions—asked if the applicant had ever sought mental health care. Fearful that an affirmative response would jeopardize their future in the military, respondents frequently avoided admitting to symptoms of combat-related stress so they could answer “no.” The 2008 change allows applicants to respond “no” if the care they received was not court-ordered and was “strictly related to adjustments from service in a military combat environment.”

“Now we have crusty generals talking about their own issues to troops,” Dr. James says. “I can remember a time when no admiral or general would ever admit to having problems like that.”

For veterans, services and resources have also increased steadily and in fact, rather dramatically. Dr. Antonette Zeiss, deputy chief for mental health services at the Department of Veterans Affairs, says her office has responded to its growing awareness of the need for comprehensive mental health services for veterans by almost doubling the number of VA psychologists in recent years, from 1,800 in 2005 to almost 3,500 today. Although VA services were originally reserved for low-income veterans, that also has changed for troops who have served in the Afghanistan and Iraq wars, she adds. All are eligible for lifetime medical and mental health care as long as they initially access services within the first five years after separating from the military.

Access doesn’t necessarily translate to services, though. Dr. Zeiss echoes the findings of the Rand report, saying that fewer than half of the 1.9 million veterans who have returned from active duty since 2002 have taken advantage of VA services.

“Almost half of those who did come in presented with a strong suggestion of PTSD or other psychological disorder,” she says. These numbers do not include possible diagnoses of TBI, which is handled by another office at the VA, she added.

Mirroring changes that have taken place in the civilian world, both the armed forces and the VA have integrated mental health services into primary care settings, which allows them to reach many more patients. Troops and veterans resistant to seeking out the help of a psychologist will often open up about anxiety and depression symptoms in a primary care setting, again underscoring the pervasive role that stigma plays in mental health issues, experts say.

“Our services are so much better than they were for previous wars,” Dr. Zeiss says. “But it’s not because the war is different or the VA is different—it’s because psychology is different. We have so much more information available about the best treatment for PTSD and depression. We can offer a whole range of evidence-based psychosocial therapies that work.”

Women in the Military

One group that stands out in their vulnerability to combat-related stress, research shows, is women.
Despite the increased presence and more versatile use of women in all service branches (no longer are their options limited to nursing and clerical positions), accommodations for them have not kept up.

“They will report for duty in a combat zone to find that only one tent and one shower has been allotted for all of them,” says Capt. Kathryn Serbin, a psychiatric clinical specialist with the Navy Reserves, explaining why women’s hygiene and physical health suffer during deployment. “Urinary tract and vaginal infections are common during deployment where resources for self care and appropriate primary care for women are scarce or unavailable.”
Capt. Serbin agrees with others interviewed for stories in this issue in identifying sexual harassment as one of the biggest—and under-addressed—challenges that women face when mobilized.

“Sexual assault in the military is greatly underreported,” she says. “Often it’s the women themselves who won’t report it. If they do, they find themselves revictimized— ostracized and further harassed. Anecdotally, I’ve heard from women that they’re encouraged not to bring their concerns forward.”

In addition to her reserve role for the Navy, Capt. Serbin serves in a voluntary capacity with the Returning Warriors Program, and co-facilitates a workshop specifically for women warriors to tell their stories. She also works as a civilian at the Naval Health Clinic Great Lakes, where she heads the gynecology clinic.

“We are recognizing the strain on our returning women,” she says. “Whether they are serving as MPs, or out with a convoy, they are supposed to just suck it up, rather than show how they’re feeling. The Returning Warriors Program gives women an opportunity to tell their stories, often the first chance they’ve had,” Capt. Serbin says. If they’re not comfortable sharing their story with a group they can write it.

“I see myself as an advocate for women—encouraging them to speak up and seek the medical care they need,” she says. “The expanding role of women in combat operations presents both an opportunity and a challenge. Further research is needed to assess the impact of war zone deployment on service women in order to narrow the knowledge gap on protection and enhancement of health and performance of military women.”

“The fact is that expectations have outpaced reality,” Dr. Twenge says. “Young people today are expected to achieve the extraordinary but it’s getting harder and harder to do. It takes more than it used to to get into a good college, get a good job, or buy a good house.” All too often, she adds, the result is “crippling anxiety and crushing depression.”

To reach her conclusions, she studied decades of results from university-administered personality inventories, and examined research that traced the rising demand for depression treatment on college campuses and that documented marked increases in panic attacks and suicide ideation among teens and young adults. She acknowledges that the trends have been accompanied by a greater acceptance of mental health issues and a growing receptiveness to treatment, but contends that those factors have not been significant enough to account for the dramatic rise in anxiety and depression in recent and current college students. “

Even when controlled for socially desirable responses, there is more anxiety and depression in this group than there was in earlier birth cohorts,” she says.

The Millennial Generation, which comprises some 78 million Americans born between 1983 and 2000, isn’t the only one with its own sociological persona or unique psychological challenges. Social scientists have portrayed Generation X as skeptical risk-takers, resourceful and independent individualists who have charted their own paths to success and their own rules for getting there. Baby Boomers, on the other hand, are known for the tight grasp they have maintained on the post–World War II idealism that saw them through the civil rights and women’s movements. They have been characterized by optimism and ambition, work has always been central to their lives and, unlike the “Xers” who followed, they have played by the rules rather than creating their own. It is this cohort—the largest ever born in the United States—that is changing the role that mental health plays in the aging process.

“Of all the Americans who have ever lived to 65, two-thirds are alive right now,” says Dr. Donald Schultz, a California psychologist specializing in geriatric issues and an affiliate faculty member in The Chicago School’s Marital and Family Therapy program.

That percentage will continue to grow as Boomers—the first of whom will reach 65 in 2011— continue to age. Eighty million strong, this generation has in recent years commandeered the public spotlight as they march steadily toward retirement, a progression that—because of their sheer numbers—threatens to drain the Medicare and Social Security coffers and dramatically increase the need for medical and psychological health care tailored to the needs of senior citizenry.

That concern—of insufficient resources to see them through their golden years—heads the list of psychological burdens that Boomers carry. Loneliness—the consequence of the divorce upsurge and geographically scattered families—registers as a close second. And not to be overlooked, there is the pressure to resist aging more adamantly than their parents or grandparents.

“They consider themselves the timeless generation, often unwilling to let go of their youth,” says Dr. Daniela Schreier, assistant professor of clinical counseling at The Chicago School. “It’s a lingering characterization of their idealism and may account for trends like Botox and plastic surgery.”

“Sixty is the new 40,” she says.

Dr. Schultz notes that, in many ways, Boomers are better equipped to handle psychological challenges than the generations that came before.

“They have seen a lot in their lives,” he says, ticking off events that range from assassinations and the unrest of the ’60s to the increased threats of terrorism today. “As a result, they have developed better coping styles, they’re less likely to be overwhelmed, and they are the first generation really willing to consider psychotherapy.”

Going a step further, Dr. Schultz suggests a correlation between the lower incidence of depression that Boomers experienced when they were younger and the fact that they continue to be less depressed than either Generation X or the Millennials today.

“The best predictor of a person during the aging years is how they were when they were younger,” he says.

The Latchkey Generation

Sometimes referred to as the Sandwich Generation because of their positioning between two much larger cohorts and the expectation that they eventually will have to care for members of both simultaneously, many in Generation X grew up as “latchkey kids.” Their mothers were the first to return to the workplace in droves, leaving them to develop a sense of independence unmatched by children who came before and after.

Young people today are expected to achieve the extraordinary but it’s getting harder and harder to do. It takes more than it used to to get into a good college, get a good job, or buy a good house.

“We are a generation that has always been in the shadow of the Baby Boom,” says Dr. Schreier, who identifies herself as an Xer. “They saw things that we never saw—things like civil rights demonstrations and campus sitins— and I think we have always felt we had missed out on that.”

But their refusal to live by rules they deem irrelevant and their insistence on a balanced lifestyle—a marked departure from the workaholic mentality of the Boomers—has established this generation as one that charts its own path. Their skepticism of everything from marriage to the rigidity of Corporate America has left an indelible mark on the household and the workplace alike. A relentless determination to do it “their way” has resulted in delaying marriage and children and then, when they decide the time for a family is right, rethinking their professional aspirations—tailoring them to meet their expectations rather than their employers’— so that they can have it all.

Having it all can be stressful, however. The American Psychological Association’s 2008 Stress in America survey found that no group feels as much stress as the Sandwich Generation, typically ages 35–54. The demands of balancing the care of growing children and aging parents while pursuing professional and personal fulfillment often takes its toll on relationships and emotional well-being. Nearly 40 percent of Gen Xers surveyed reported “extreme levels of stress,” compared with 29 percent of Millennials and 25 percent of those older than 55, an age bracket that includes both Boomers and the World War II-era “Traditionals.”

Dr. Schreier contends that the flexibility and adaptability that are hallmarks of her generation also manifest themselves in a tendency to move around—from location to location and from partner to partner.

“It is a generation of nomads,” Dr. Schreier says. “Many never settle down into a job or a relationship. They adapt easily to new situations, but they also feel torn, like they are always floating and wondering ‘where do I belong’?”

Generation Y

But it is the Millennials—aka Generation Y or the Net Generation— who have dominated headlines, blog traffic, and water-cooler conversation since they began coming of age in the last decade. Terms used to define them range from “entitled” and “narcissistic” in Dr. Twenge’s books to “overprotected, overscheduled, and socially conscious” by psychologists such as Dr. Dave Verhaagen, author of Parenting the Millennial Generation.

Parents today feel uncomfortable in their roles as authority figures. They want to be their kids’ friends and have their kids’ approval rather than the other way around. They have brought the ‘everybody-is-equal’ philosophy of their youth to their roles as parents.

While narcissism, which Dr. Twenge references loosely as too much self esteem, may seem a heavy—if not downright judgmental— label to pin on today’s teens and twenties, she grounds her assertion in data collected for a 25-year time span, evidence she considers so compelling that it led to her most recent book, The Narcissism Epidemic.

“When looking at the incidence of Narcissistic Personality Disorder (NPD), you would expect to find higher rates in those who have lived longer and had more time to experience episodes of NPD, but that’s not what the research shows,” she says. She cites a 2005 National Institutes of Mental Health study of 35,000 respondents that reports that people in their 20s were three times as likely to have experienced an episode of NPD than people over 65.

“I was blown away by the fact that the prevalence was tripled in a group that had only lived one-third as long,” she says. To further prove her point, she points to evidence gathered from decades of Minnesota Multiphasic Personality Inventory (MMPI) results. In the 1950s, only 12 percent of respondents agreed with the statement “I am an important person.” By the late 1980s, more than 80 percent agreed.

Many psychologists and parenting experts attribute the trend to the fact that Millennials have often been treated more like partners than children as they were growing up. They cite families who allow a 6-year-old to choose the family car and pre-teens to decide where to go—or even whether to go— on vacation. It is a phenomenon spawned by the Baby Boomers who are doing much of the parenting today, they claim. As a generation that identifies strongly with the equal-rights marches and antiestablishment protests that defined their seminal years, they can find it hard to deal with the hierarchy of the “traditional” family that assumes parents make the rules and children follow them.

“Parents today feel uncomfortable in their roles as authority figures,” Dr. Twenge says. “They want to be their kids’ friends and have their kids’ approval rather than the other way around. They have brought the ‘everybody-isequal’ philosophy of their youth to their roles as parents. The downside comes when kids grow up and realize they are not the center of the universe.”

Dr. Verhaagen, who has spent much of his career providing mental health services for children and adolescents and is currently a managing partner at Southeast Psychological Services in Charlotte, N.C., agrees.

“Is this generation more narcissistic? Probably. After all, they’ve been raised by parents who taught them that they can do anything,” Dr. Verhaagen says. “It’s both good and bad. It’s great to believe in yourself, but not so great if problems have always been solved for you and you haven’t been given the opportunity to fail.”

The problem solvers that he references—“helicopter parents” as they are known in 21st-century lexicon—are mothers and fathers who “hover” over their children, serving as ubiquitous buffers between them and the occasional hard knocks that life has to offer.

“The notion of the helicopter parent is not made up and not over-blown,” Dr. Verhaagen says. “Everyone who works in academia has stories about the father who calls the professor to question a grade or the grandmother who is on the phone with the registrar’s office about the registration process.”

The result is a generation that lacks the ardent independence of Generation X’s latchkey kids yet struggles continuously to live up to their parents’ expectations. Add to that the dependence on the technology and social media that have revolutionized their communication channels and turned them into achievement-oriented multi-taskers.

“One thing that is clear and is that this generation is more stressed than any previous generation,” Dr. Verhaagen says. In contrast to Dr. Twenge’s assertions, however, he believes that Millennials are handling this pressure. He points to data produced by the Centers for Disease Control and Prevention (CDC) that track trends in youth risk behaviors associated with stress, including the use of alcohol and illegal drugs and suicide related behavior.

“There are lower rates of drug use, lower rates of pregnancy and STD (sexually transmitted diseases). Most of the indicators for high-risk behavior are either trending down or holding steady.”

The reason? Dr. Verhaagen offers several: goals, family values, and a determination to do meaningful work. Despite frequent declarations that this generation is the “most coddled” in history, he contends the very actions cited for creating entitled, narcissistic youth have also built up a degree of resilience. They may be stressed but they have goals to work toward. They may be overscheduled, but they’re not idle.

“They might be our next generation of heroes,” he says. “They’re a good generation—well nurtured, able to relate well to others, and with a strong sense of the future. They have the potential to be great. Time will tell.”

Yet, it is not only the Dow—spewing daily evidence of infrequent rallies and steady declines—that reflects what is happening in America, and abroad, these days. Another, newer measure, the Gallup-Healthways Well-Being Index, tells the story of a global economic crisis in the language of psychologists: the human toll, the effect that the financial downturn is having on people.

“We’re in a happiness recession,” says economist Justin Wolfers, associate professor of business and public policy at the University of Pennsylvania’s Wharton School. “We have found the most robust determinant of happiness to be the current state of the economic cycle.”

Dr. Wolfers and colleague Betsey Stevenson have studied three decades of data produced by the Gallup-Healthways Index and several earlier polls that measured subjective well-being (the Gallup World Poll, the World Values Survey, and the U.S. General Social Survey) and identified strong parallels between general well-being and the ups and downs of the economy. Low points plotted on their “happiness charts” occurred in 1973, 1982, 1992, and 2001, each a year at the center of an economic recession.

Many psychologists, however, are quick to distinguish the current economic crisis from previous recessions. Dr. Nancy Molitor, a psychologist in private practice in Wilmette, Ill., and a public education coordinator for the American Psychological Association (APA), says that the levels of stress she is seeing in “virtually all” of her clients exceed anything she has seen in 22 years of practice.

“It’s hit everyone—CEOs, teachers, small-business owners, whether they’re 25 or 65,” she says. “It’s far worse than after 9/11. Then, there was a bad guy to blame and it gave everyone a common purpose. And after a while, anxiety began to fade because what had happened was in the past. But now, there’s no end in sight, and no clear fix that people can pin their hopes on.”

As it has become increasingly apparent that the recession is a reality that cannot be ignored, Dr. Molitor says that she has watched the condition of her clients steadily deteriorate.

“In the fall, I saw a lot of anxiety as the economy worsened. But now what I see is depression, and often absolute despair. People are terrified—terrified of losing their jobs or their houses, terrified of needing help and not being able to afford it. People aren’t interested in the deep psychotherapy they used to come for—today it’s just about crisis management.”

Dr. Rosalind Dorlen, a psychologist in Summit, N.J., agrees. Summit’s location—directly across the Hudson River from Wall Street—places her practice at “the epicenter of the financial downturn” and accounts for the large number of investment professionals among her clients.

“I’ve had many clients who have lost their jobs, and at least one whom I had to hospitalize because he let his drinking get so out of control after losing his job. Hitting bottom has sparked such intense reactions in so many. I have no patients who are not affected.”

Clients who are turning to psychology professionals for help in navigating the emotional consequences of the recession run the gamut: out-of-work executives brought in by their spouses because they were unable to pull themselves together enough to make the appointment; workers who still have jobs but live in fear of being included in the next round of company layoffs; sixty-somethings who have saved diligently for retirement only to find their 401(k)s worth a fraction of what they had anticipated.

Happiness and Output Gap in the United States

For many on the brink of retirement, it’s about more than their withered stock portfolios though, Dr. Molitor says. Often they find themselves stuck with a big house that they can’t sell, adult children who are losing their jobs and moving back home and—because they have lost their nest eggs and can no longer afford to retire—fear of losing their own jobs.

The stress that psychologists are seeing was documented in a recent APA report, “Stress in America,” published in October 2008. While data for the study was collected before the brunt of the financial meltdown, it demonstrates Americans’ growing concern about the economy and their ability to provide for their families. Nearly half of those surveyed reported that their stress level had “increased significantly” over the past year, with as many as 30 percent rating their average stress levels as “extreme.” Money and the economy topped the list of stressors for eight out of 10 people surveyed, and those concerns increased steadily during the six-month datacollection period. Stress about the economy jumped from 66 percent in April to 80 percent in September, while concern over housing costs increased from 56 percent to 62 percent, and job stability fears rose from 48 percent to 56 percent.

The Gallup-Healthways Index confirms the stress levels documented by APA, stating its findings in terms of the percentage of Americans who are “thriving,” “struggling,” and “suffering.” In early November—just weeks after the Lehman Brothers collapse that many point to as the pivotal point in the crumbling economy—the poll showed that 60 percent of Americans were struggling, up a full 14 percentage points from January. At the same time, the weekly average of thriving Americans hit a new low of 36 percent. Meanwhile, the percentage of people suffering—unable to afford the bare necessities—has inched up from 4 to 5 percent.

The Gallup data is particularly significant because of its magnitude. Since January 2008—when the index was launched—1,000 individuals have been surveyed every day. With 350,000 annual interviews to work with, researchers have access to exceptionally rich data that can be “sliced and diced” in numerous ways. The questions asked provide information for six separate indexes, including two—a mood scale and a life evaluation scale—that feed into the happiness numbers.

“Both are pretty sensitive to the economy,” says Jim Harter, chief scientist for workplace management and well-being at Gallup. “Life evaluation is intended as a more long-term measure—meant to gauge how people feel about how their lives will be five years out. Mood, on the other hand, reflects the daily ups and downs that we all experience.”

November and December represented the lowest points for life evaluation, he said.

“But while mood bounced up and down and hit all-time lows in early February, we saw the life evaluation numbers gradually climb as we approached—and then passed—the presidential inauguration. The numbers coincided with Obama’s approval rating and, I think, reflected the hope people were beginning to have for the future.”

In Dr. Harter’s view, the most significant finding has been the “sheer amount of fluctuation” that occurs in the mood of the country—plummeting from a high of 67 percent reporting “a lot of happiness without a lot of stress” on Thanksgiving to 35 percent on the days when the most troubling economic announcements were made.

A Burden on Psychologists
The implications for the psychology profession are enormous, Dr. Harter says. Because many people identify their workplaces as major sources of stress, he suggests using that knowledge to design more positive workplaces—places where people can connect and satisfy their basic human needs for socialization.

“If we know what makes a good day for people, interventions can be designed that make more of those good days come about. We know that the best predictor of daily mood is the amount of social interaction time a person spends, and that it takes six to seven hours of social time to optimize a day. If the person works in a negative environment, it takes even more.”

Evidence of the correlation between the financial crisis and wellbeing goes beyond the numbers produced by surveys, with requests for therapists’ services continuing to increase as the economy has faltered. At the end of 2008, ComPsych—the world’s largest provider of employee assistance programs—reported that requests for psychological assistance had risen by almost 20 percent in the last three months. The company’s CEO, Richard Chaifetz, attributed the increase to mounting concerns about the financial situation.

APA has responded to increased stress levels with a public education campaign, through which information on coping with the economic crisis and its impact is disseminated. Professional psychologists report that they are networking more than ever in an effort to share strategies for helping their most distressed clients and dealing with the dramatic increased demand for psychological services.

“We’re working to get the message out that there are ways to manage stress, both for clients and therapists,” says Dr. Dorlen, who, in addition to her private practice, coordinates regional public education activities for APA.

“Psychology is not a bullet-proof profession,” she says. “Those of us in the trenches practicing psychology have been affected as well. Even those who haven’t yet been directly impacted by declining reimbursements and patients’ inability to pay for services are experiencing anxiety about their practices.” To address the challenges that her colleagues are facing, she has compiled a list of strategies for practicing psychology in an economic crisis, published in the January/February issue of The National Psychologist.

The increasing demand for mental health services has hit nonprofit organizations as well as private practitioners. At Pillars, a Chicago-based social service agency that provides a wide variety of integrated behavioral health and educational services, the requests for crisis intervention services resulting from financial stress have tripled in recent months.

“We’re seeing more requests from people who are homeless, in need of food, and suffering from depression or anxiety due to job loss, financial stress, and foreclosure,” says John Shustitzky, president and CEO of Pillars. “We currently have a waiting list of more than 100 people, a situation that is made even worse by the fact that funding cuts have forced us to eliminate 30 staff positions. This means fewer available clinical hours, and increased caseloads—and stress levels—for the staff who remain.”

Connecting Psychology and Health

Practicing Psychology During an Economic Crisis, by Rosalind S. Dorlen, Psy.D.

A long-term consequence of recession-fueled stress that many psychologists fear is the impact on the population’s overall health. Some turn to alcohol and drugs as coping mechanisms, while others allow healthy eating and exercise habits to fall victim to deflated moods and decreased motivation.

“Gallup’s next big well-being project is an in-depth analysis of the relationship between psychology and health,” Gallup’s Dr. Harter says. “We know that psychological outlook is a leading indicator of healthy behavior, but we want to understand more about how our good or bad moods might impact our physical health.”

The Well-Being Thermometer: What it Measures
The Gallup-Healthways Well-Being Index™ is a daily report that functions much like the Dow-Jones industrial average. At least 1,000 individual interviews are collected every day, 350 days a year, and the data is used to provide a comprehensive, real-time view of the public’s well-being in the United States and abroad. Gallup terms it “the most ambitious effort ever undertaken to measure what people believe constitutes a good life.”

In APA’s “Stress in America” survey, 77 percent of respondents reported stress-related physical symptoms, including fatigue, headaches, and upset stomachs. And while a majority reported knowing that exercise is valuable in reducing stress and maintaining health, many cited more sedentary activities—such as listening to music, watching television, or reading—as the activities they chose to manage stress.

The gap between knowing what to do and actually doing it is not confined to eating habits and fitness regimens though. Despite widespread (69 percent of those surveyed in the APA poll) recognition of the benefits of mental health support, only 7 percent sought professional help to manage the stress of the past year.

“It’s often difficult for someone—especially someone used to a position of authority at work or in the family—to seek help,” says Dr. Michael Komie, affiliate professor of clinical psychology at The Chicago School. “They’re used to being in control and so much of their identity is tied to that role; sometimes they just can’t get beyond it. If they do reach out for support, they’re often more comfortable with what they regard as a natural support system—a church, synagogue, or mosque. When I do get calls to meet with them, they’re likely to come from a family member.”

Ups and Downs of Happiness

During his years in private practice and as a vocational consultant to the St. James Cathedral Counseling Center in Chicago, Dr. Komie has worked often with the casualties of corporate downsizing, factory layoffs, and small business failures. He has witnessed the varying impact the economic hardship has had across demographics—blue-collar workers and white-collar professionals; men and women; Gen Xers, Boomers, and seniors; Caucasians, Asians, Latinos, African-Americans, and immigrants.

A white-collar Baby Boomer who has never seriously contemplated unemployment can face a more complicated coping challenge than a blue-collar worker who is paid by the hour and accustomed to more cyclical employment.

While the response to job loss doesn’t vary greatly, Dr. Komie says, different demographic groups rely on different coping mechanisms.

“A white-collar Baby Boomer who has never seriously contemplated unemployment can face a more complicated coping challenge than a blue-collar worker who is paid by the hour and accustomed to more cyclical employment,” he says, adding that the task of finding new employment isn’t as daunting for someone who has been through it before and expects to do it again. This is particularly concerning, he says, because—as the nation has moved from a manufacturing economy to a service-based economy—layoffs are more than twice as likely to affect white-collar jobs as they were several decades ago.

While the APA survey reported that women are bearing the psychological brunt of the economic crisis—reporting higher levels of stress than men—Dr. Komie finds them to be more resilient in cases of job loss.

“Women tend to be more flexible about their work identities, largely because they’re used to balancing multiple social roles,” he says. “Men, especially the older men, see themselves as the breadwinner, and are much more likely to respond with a sense of guilt and shame that they’re not able to support their family.”

The Happiest States of America

Psychologists and economists alike agree that the current economic crisis has wielded a larger—and less class-conscious —blow on national well-being than earlier recessions. No longer a predicament of the working class alone, the recession of 2008-2009 has proved itself an equal-opportunity enemy.

“This is the first recession where the middle class has been as affected as the people working low-skill jobs,” Dr. Wolfers says, adding that the ramifications are being felt across age and cultural groups and documented in terms of both fiscal and emotional well-being.

The “happiness recession,” which he proclaimed when discussing his analysis of Gallup-Healthways data, is likely to be with us for a while, Dr. Wolfers says. Moods and life satisfaction measures are likely to continue mimicking the contours of more dollar-centric indexes, but as things start to improve, life evaluation may show itself to be a step ahead of the Dow.

“Well-being tends to be forward-looking,” he says. “A lot of it is rooted in expectation.”

Traditionally, this might not have been seen as a job for a psychologist. A physical therapist, yes; an occupational therapist, definitely. While psychology would have played a crucial role in helping the patients deal with the emotional aftermath of their circumstances, the challenge of relearning skills might more typically have been left to the purview of other rehabilitation therapists.

Dr. Mozzoni, a psychologist with degrees from Harvard and Florida State, used applied behavior analysis techniques to reteach the functional motor skills known in the profession as the Big Six Plus Six—reach, point, touch, grasp, place, release and twist, pull, push, tap, squeeze, shake. The results, which he published, were significant: both patients progressed from a total inability to dress themselves to being able to perform all the dominant and nondominant-side functions needed to button, zip, and pull themselves into their clothing.

“ABA has found its niche in areas that cannot be effectively addressed by other areas of psychology,” Dr. Mozzoni, regional program director for the Learning Services Neurobehavioral Institute in Colorado, says. “You can’t talk somebody out of autism or a developmental disability. It takes a very different approach to addressing an individual’s problems.” The therapy he provides involves breaking down complex activities into small discrete tasks and helping patients master each task individually, guiding brain injury survivors through the process of relearning skills lost to accident or illness.

“It’s a matter of focusing on one task at a time so they can experience success with each one, and then putting them all back together so they function in an everyday environment,” Dr. Mozzoni says.

Applied behavior analysis, or ABA as it is called by those who practice it, is a rapidly growing discipline that uses a natural science approach to bring about socially significant changes in an individual’s life and in the world at large. The field’s strength lies in the systematic collection and analysis of data to validate incremental improvements in observable behavior.

It’s an area with endless applications… It can and should be used in any aspect of life that involves human interaction. Any time that behavior is important and change is valued, ABA is the way to go.

Known best, and practiced most, as a treatment for individuals diagnosed with autism, ABA has found a home in fields as disparate as the brain injury rehabilitation that Dr. Mozzoni practices, sport psychology, organizational management, regular and special education, gerontology, health and fitness, gambling addiction, crime and delinquency, sex therapy, neuroscience, animal behavior, and more.

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“It’s an area with endless applications,” Dr. Joe Layng, senior scientist and co-founder of Headsprout, a Seattle-based company that has used ABA techniques to make dramatic improvements in the fundamental academic skills of some 300,000 children, says. “It can and should be used in any aspect of life that involves human interaction. Any time that behavior is important and change is valued, ABA is the way to go.”

Changing Lives

Sue, a profoundly mentally retarded woman who has spent her life in an institution, is another client who has benefited from behavior analysis therapy. At 35, she spent her days engaged in self-injurious behavior and appeared most comfortable when she was physically restrained.

Dr. David Pyles, who serves as chief of behavior analysis for the Illinois Division of Developmental Disabilities, used an ABA technique called fading (gradually removing a desired stimulus) to bring about the behavioral changes he sought. He replaced constraints with wrist weights, which he only allowed Sue to wear when she was not inflicting injury on herself.

“It took a while but she eventually learned that when she just cooled her jets she could enjoy wearing the weights, which evidently provided a stimulus that she liked,” Dr. Pyles says. He then began reducing the size of the weights and eventually replaced them with a sweat band, which in turn gave way to a bracelet. He describes it as a classic ABA scenario that ended Sue’s self injuring and her need for restraints.

Although behavior analysis has roots deeply entrenched in psychology (psychologist B.F. Skinner developed the set of principles that frame behaviorism), ABA differentiates itself from the social science base of its mother discipline. ABA practitioners agree that the precision with which they collect and analyze data that documents behavioral changes makes the field more analogous to the “hard” sciences such as biology, physics, or chemistry.

A common criticism of the field involves the perception that behavior analysts don’t share their clinical psychology colleagues’ interest in what a client feels.

“We get a bad rap for ignoring emotions and feelings,” Dr. Rachel Tarbox, associate professor of Applied Behavior Analysis at The Chicago School, says. “We don’t ignore them, though. We treat feelings and emotions as behaviors.” Behavior analysts, she explains, take the perspective that prevailing environmental conditions need to be analyzed with respect to their effects on human behavior.

“By manipulating these behavior-environment contingencies, we can bring about robust behavioral changes, which in turn, lead to individuals living happier and more productive lives,” Dr. Tarbox says.

As lead ABA faculty at The Chicago School’s Los Angeles Campus, Dr. Tarbox finds that many of her students have entered the field with the goal of working with children with autism. It is as a therapy for this disorder that applied behavior analysis has received the most attention.

“ABA techniques, when provided consistently and intensively as early intervention, can—and do—virtually eliminate the diagnosis of autism in young children,” she says. “As dramatic as that sounds, for those of us who do this every day, it’s just an accepted fact. To question it as an overstatement would be like questioning whether penicillin really cures ear infections.”

One distinction that separates behavior analysis from traditional psychology is what Dr. Chuck Merbitz, chair of The Chicago School’s Applied Behavior Analysis program, describes in terms of the inductive versus deductive model of determining treatment plans.

“Even though I value the opportunity to work closely with colleagues in other areas of psychology, I sometimes feel that we’re more like engineers than social scientists,” Dr. Merbitz says. “Psychologists typically use a hypothetical, deductive model of statistical analysis to decide a course of treatment. Behavior analysts use an inductive model; we pile up facts about a certain person and evolve individualized procedures based on those facts.”

Dr. Tarbox agrees.“We stay away from statistical analyses because what is statistically significant may not be socially significant.” She offers the example of an individual suffering from depression who experiences a 10 percent decrease in symptoms while on a certain medication.

“That result can be considered statistically significant. But the patient is still depressed 85 percent of the time so the results aren’t socially significant. As a behavior analyst, I would want to make changes in the patient’s environment to try to address the source of her feelings.”

A 75-year-old discipline

Tracing its roots back to the 1930s and Skinner’s work with operant conditioning, ABA developed from the experimental psychologist’s fascination with the intersection of environment and behavior. All human actions, he came to believe, occur in the presence of environmental stimuli and can be altered by varying those stimuli.

ABA techniques, when provided consistently and intensively as early intervention, can—and do—virtually eliminate the diagnosis of autism in young children… As dramatic as that sounds, for those of us who do this every day, it’s just an accepted fact.

The concept of behavior analysis—or radical behaviorism, as Skinner termed it—represented a departure from prevailing psychological theory, which attributed actions instead to internal factors such as emotions and feelings.

 Fast forward to the 21st century, when 135 universities— including 28 outside the United States—have approved course sequences to prepare behavior analysts, and a national organization oversees the certification of the approximately 6,000 board-certified behavior analysts (BCBAs) and associate behavior analysts (BCABAs). It is a rapidly growing profession that has doubled its number of certificants in the past five years, from 2,838 in 2003 to 5,948 in 2008.

Erika Wilhelm, a second-year ABA student student, relies on her clipboard to record behavioral changes in a play-based setting.

Although the field’s growth can be attributed largely to increasing demand for skilled professionals, Dr. Gerald Shook, chief executive officer of the Behavior Analyst Certification Board (BACB) admits that there is not a way to accurately quantify the need.

“There is no doubt that we need more BCBAs but exactly how many is a hard question to answer—except to say that there are more people interested in the profession, more people getting certified, and more schools introducing programs to train them. And every single graduate gets a job,” Dr. Shook says.

One area of shortage is in the specialty that Dr. Mozzoni practices. Every year, 99,000 Americans receive brain injuries that result in lasting disability; this includes combat veterans (the Veterans Administration estimates that TBI affects 22 percent of military personnel who have been wounded in action) and survivors of motor vehicle accidents, strokes, heart attacks, and near drowning.

“There are only between 50 and 100 of us who have been trained specifically to work with brain injury in this country,” Dr. Mozzoni says. “Although more and more people are going into ABA every year, the majority are going in it to work with autism— that’s the area that is getting the most public attention.”

One indicator that ABA is receiving increasing recognition as an effective treatment for some areas of disability is changing health insurance laws.

“A number of states are now requiring that treatment by a BCBA—particularly for autism and other developmental disabilities—be included among services eligible for insurance coverage,” Dr. Shook says. He cites TRICARE , the health plan that covers military families, which now pays for ABA services for children with autism, as long as providers are BACB certified.

One Field, Many Applications

One does not need to be institutionalized or disabled to benefit from behavior analysis, which is now used throughout the world. (BACB data shows that the organization certifies professionals in 28 countries and on five continents.) It is used by Fortune 500 companies to improve workplace environment, and by organizations of all kinds to solve management problems. Its use in sports, health, and fitness, which dates back at least to the 1970s, has helped improve golf swings, fine-tune ballet movements, see thousands through popular weight-loss regimens, and serve as the springboard for workplace wellness programs.

“It’s more of a blended area than other ABA applications are,” says Dr. Amanda Adams, who teaches in California State University-Fresno’s behavior analysis program and is active in the Sports, Health and Fitness Special Interest Group of the Association for Behavior Analysis International (ABAI). “It’s incorporated into many areas but the people who practice it most often do it as a hobby—maybe coaching a child’s soccer team.” She adds that no university programs offer a specialization in this application of ABA.

“When you see the techniques used in gyms and wellness programs, they’re usually not overseen by someone who has been trained specifically in ABA. A workplace wellness program is probably run by a registered dietician—it would be great if you could find someone who was both a dietician and a BCBA, but that doesn’t happen very often,” says Dr. Adams, who, as a certified yoga and kick-boxing instructor, has used her skills to increase compliance in exercise routines.

Despite the proliferation of ABA applications, it is a science that struggles with misconceptions and, occasionally, controversy. The fallacy that behavior analysts cite most frequently is the belief that it is a treatment that is grounded in negative—and sometimes harmful— punishment techniques. There are those, they claim, who equate ABA with electric shock therapy and similar painful, or humiliating, responses.

“There are people who criticize us for being overly harsh,” Dr. Adams says. “While there were early researchers who incorporated mild punishers into their research, we use a much softer approach now—with children, it’s always play based. It incorporates the natural environment and is based on positive reinforcement.” Dr. Tarbox puts it more simply.

“ABA is all about getting the good stuff and avoiding the bad stuff,” she says.

The bottom line, behavior analysts agree, is that ABA works. Its focus on collecting and analyzing precise measurements at every juncture ensures that if a change in environmental stimulus is not working, it can be changed immediately.

“We can often tell within three days if a procedure is working,” Dr. Merbitz says. “The last thing we want to do is to prolong an ineffective treatment. When our data tells us that we’re not achieving the results we want, we make changes and continue to record our data points. Our decision-making is based, at every step along the way, on the behavior we observe in the person we’re treating.”

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Dr. Merbitz, a former tenured professor at the Illinois Institute of Technology, joined The Chicago School in 2003 to spearhead the institution’s response to the mounting need for ABA professionals. The M.A. in Clinical Psychology Applied Behavior Analysis Specialization, which was launched the following year, is one of only two approved university- or professional schoolbased master’s-level programs in Illinois, and enrolls about 50 new students each year. A companion doctoral program, introduced in fall 2008, is the only one of its kind in the state. Both degree options are also offered at The Chicago School’s Los Angeles Campus where the Psy.D. program has the distinction of being the only ABA doctoral program in the world designed for fulltime working professionals.

There seems to be little doubt that ABA will continue to grow as an area of expertise. As the need increases—and the alarming ascent in autism diagnoses is just one factor contributing to this trend—there will be an escalating demand for BCBAs. Concurrently, behavior analysts are finding new potential for application of their skills in every corner of life.

“The sky’s the limit,” Dr. Pyles says. “The world is a big place for us. We can’t fix everything with ABA but we won’t stop trying.