Jerome Kagan: Psychology Is In Crisis
Jerome Kagan is known as one the fathers of developmental psychology. Now in retirement from Harvard, his new book, “Psychology’s Ghosts,” is an indictment of the field he helped shape, calling into question research psychology’s most basic methods and assumptions.
“Psychiatry is the only sub-discipline in medicine where the diagnoses are only based on the symptoms,” Kagan told host Meghna Chakrabarti. “You’re treated for depression on the basis of your symptoms when your depression could come on for a half a dozen different reasons and the reasons are important in how you treat the patient.”
Kagan also explained how psychology and psychiatry need to incorporate more neuroscience. “Every physician will order an x-ray, a blood and a urine test to make sure that the diagnosis is accurate. Contemporary psychiatry isn’t doing that,” he said.
A full transcript of the interview appears below.
Here’s an excerpt of his book:
- Jerome Kagan, author of “Psychology’s Ghosts”
Meghna Chakrabari: Your book is really quite an indictment of psychology as a research pursuit — how it’s researched, how psychological or psychiatric disorders are diagnosed and how they’re treated. One of your fundamental critiques in the book is the way that we classify and even diagnose mental illness. You’re saying that the way it’s currently done is inadequate. Why?
Jerome Kagan: It’s inadequate because, if you think about all the physical diseases, they are diagnosed not by the symptoms you tell your doctor, but by the cause. Malaria means not that you have a fever but that you have the malarial parasite.
Psychiatry is the only sub-discipline in medicine where the diagnoses are only based on the symptoms. You tell your doctor you can’t sleep and you have no energy and he says that you’re depressed. You’re treated for depression on the basis of your symptoms when your depression could come on for a half a dozen different reasons and the reasons are important in how you treat the patient.
Isn’t what you’re saying largely because that’s all psychiatrists currently have? We don’t actually understand the medical or biological origins of so many psychiatric disorders.
That’s right, and that’s a very good point. But there is inadequate research being done on the life history causes. In medicine, if you have a disease, immediately several hundred or a thousand investigators start at once — take AIDS — to find out what was the cause.
There is very little research going on on the role of class, on the role of life history, on the role of who you identified with, your religious identification, your ethnic identification. In other words, there’s a whole complex set of causes; they are not being studied.
Is there too much focus on trying to find these biological origins?
The problem is that biology made extraordinary advances, both in genetics and in ways to measure the brain. Because that technology is available, people rushed over to that side and hoped that that would solve the problem, abandoning the other half.
To put it briefly, biology says you’re likely to be vulnerable to this envelope of illnesses. Your environment, your setting, your class, your culture, where you live disposes and selects from that envelope the symptoms you might develop. And that domain is not being studied adequately.
On the one hand, one might think psychology as a research practice and psychiatry as a medical practice are the fields that would be best predisposed to dealing with how environmental and historical and cultural factors play into our well-being. But on the other hand, scientists are trained to try and strip away confounding factors. To try and say, well, when we control for things like race and control for things like country of origin, we can actually say these things don’t matter and the core cause is X. But you’re actually asking them to do the opposite of that.
Precisely. Because — as I read the literature, and I have many people on my side — the best predictor today in Europe or North America of who will be depressed is not a gene and it’s not a measure of your brain; it’s whether you’re poor. And that makes sense.
If, in a country like ours with an enormous range of income, you’re poor and you’ve been poor since you were a child, which means that your medical care is less adequate, your diet’s less adequate, you’re probably fighting some low level infections and you’re poor — that’s a pretty good reason to be depressed.
That then is taken out because we’re looking for the genes. Now, in fact, there probably is 10 percent of depressed who do have a specific genetic vulnerability and then we’re missing the 80 percent who don’t have a specific genetic vulnerability — they have a very good reason for being depressed.
My tongue in cheek response to that: Poverty’s hard to solve but it’s easy to write a prescription.
That’s the problem. We’re hiding. We’re hoping. And I think that the hope is probably not a wise one. We’re hoping that we will discover the biological causes and treat the biological causes and we won’t have to worry about the societal causes and the individual lifestyle circumstances that people deal with. That’s the hope. My own view — and I’m not alone — is that is denying the problem.
Talk about why you wrote this book. It began with some very interesting conversations you had with former Harvard president Derek Bok about the nature of happiness.
I was working on several papers and I then I read this excellent book by President Bok which was called “Politics and Happiness.” He was summarizing a large body of research; right now and in the last decade hundreds of investigators have been asking people from almost every country in the world, “How satisfied are you with your life?” And they’re writing up that some societies are good and some societies are bad. But my problem with that is that there are many reasons why a person in Ghana and a person in Los Angeles would give you the same answer.
Your answer to the question “How satisfied are you with your life?” is a function of four conditions:
- Temperament: Some people have wonderful temperaments; nothing bothers them.
- Values: What values did you set up as a child that you had to meet? If you set high values, you’re not going to be happy. And if you set easy values, you’re going to be happy.
- Comparison: Who are you comparing yourself with? If you’re in Los Angeles — who are you comparing yourself with when you say, “I have a pretty good life.”
- Country: What country are you in? If you’re in Denmark, you say, “I’ve had a wonderful life!” Denmark’s the best country in the world. If the Danes don’t change anything in Denmark but now let the Danes know they’re 25th in the world (there are 24 countries better than they) suddenly every Dane will say, “I’m not very satisfied with my life.”
So we have four factors. Those combinations change across the world. So I don’t know what the statement means when someone in Ghana, Cairo, or Los Angeles, “You know, I’m pretty satisfied with my life.”
Sometimes I wonder maybe we’re just trying to overcomplicate things and why can’t we just accept the fact that how a person reports his or her well-being may actually be the most accurate measure of what they are feeling at the time.
I doubt it. Suppose I change the question and we went around the world and said, “How confused are you about your life?” Everybody would give an answer. Do you know what that answer means? You go up to a person in Helsinki, you say, “How satisfied are you with your life?” He or she has never thought about that and so they give you an answer. Because people will give an answer does not mean the answer has any good meaning.
It sounds like you’re demanding that psychology as a research practice and psychiatry as a medical practice take into account context, context, context. And that introduces a lot of different complication in terms of language, culture, socioeconomic status, etc. How is it then that you would like to see the field move forward? Do you have any set of practical recommendations?
Yes. Let’s take the field of personality. Right now we have terms like introvert, extrovert, shy, anxious. Notice those words are naked. They don’t say with whom you’re introverted, when you’re introverted in what settings you’re introverted.
In other languages — take Japanese for example. There’s no word for “leader” in Japanese. There’s only a word for leader of a corporation, leader of a radio station, leader of a platoon. Because they understand that a person who’s a good leader of a radio station might be a lousy leader of a platoon. And the same thing for extroversion, introversion, shyness.
And that’s a problem with the English language. And the problem is that 80 percent of research on personality is done by Americans using the English language. The English language is a very bad language for talking about personality because it doesn’t tell you the context, the setting, with whom you are where this trait might be expressed.
Do you worry that some people might respond to what you’re saying and feel like Jerome Kagan is actually asking us to step away from the core tenets of the scientific method whereas for the past 50 years there’s been this idea that you can apply science to psychology.
No, because, as a matter of fact, when I joined the field of psychology 60 years ago, it was one of the most respected fields. Biologists and physicists now say what I’m saying; they say the psychologists are not doing the kind of science they should be doing. Every biological reaction, every chemical reaction is in a context. Otherwise you must control for the temperature, the pressure, the acidity of the solution. So when psychologists ignore the context in which people behave, they are not doing good science.
A lot of people might think the way the research is done is one thing but psychology and therefore psychiatry have a direct impact on the lives of millions of people. In your book you write that the fifth version of the Diagnostic and Statistical Manual is due out soon; it’s the bible by which many people are diagnosed. What is it that you’re recommending that might change the impact that people feel?
To be specific about the diagnostic manual, I would hope — it’s too late now for this edition, but in the next edition, 2015 or 2016 — that the categories of mental illness, the 206 or 210, take into account what the psychiatrist seeing the patient believes is the cause.
In other words, “I think because I’ve gathered some data (some genetic data, some brain data) — I think this is due to a genetic vulnerability,” versus “I think this depression is due to the fact that this person is living under horrible circumstances, and I think they should be treated differently.”
One brief example: Gerard Bruder in New York City has shown that there are two kinds of depressives. They look alike and they tell the psychiatrist exactly the same symptoms. But one of them has a very active left frontal lobe; they do better when you give them an antidepressant drug. Another group of patients have the same symptoms, but they’re more active in the right frontal lobe; they don’t improve on the drug. So why don’t psychiatrists when they do their diagnosis say, “I’m going to get an EEG and I’m going to find out whether you have a greater left active frontal lobe or a greater right and then I’ll decide whether I’m going to prescribe this antidepressant.”
I remind you: Every physician will order an x-ray, a blood and a urine test to make sure that the diagnosis is accurate. Contemporary psychiatry isn’t doing that.
There’s this burgeoning field of neuroscience. Everyday seems to bring about a new discovery. Are you calling for an even tighter, more intricate bind between psychology and neuroscience in how it’s practiced in doctors’ and clinicians’ offices?
Absolutely. Now, the psychiatrists I respect — their reply to what I just said will be, “The HMOs won’t pay for that EEG.” That’s the problem.
This has to be a concerted effort by the profession to tell the HMOs that, “We will be able to treat our patients better if I can order on some patients an electroencephalogram so I can see whether this person should get the drug or not.” Once it gets involved with money and payment, the psychiatrists know that they won’t get reimbursed and the patient will have to pay for it; and they don’t want to give that burden so they don’t do the test.
You are one of the giants in the field; you helped shape modern psychology. Why did you decide to write this book now?
Well, I love psychology. I entered it with great passion and great affection. And so, like a child that you stood with for so long, when you see it making small errors you try to correct it. And so the motive for the book was affectionate — like you say to a child, “Now, that’s really not a good thing to do.”
In that case, is it really a field in crisis or a field that’s at a moment of ongoing development, of critical development?
I think it’s a function of whether you want to emphasize how serious the crisis is. I think that it is more serious than you’re implying.
Why? Is that because it’s actually had an impact on how people are treated?
This morning on WBUR, I heard on the news, Morning Edition, that the Centers for Disease Control said that 1 out of 88 children in America have autism. That’s absurd! And not telling the audience, what do you want? That worries mothers. It’s only because doctors are prescribing autism for children who don’t really have autism.
This is very serious. The autism that was known to psychiatrists in 1940 — that’s 1 in 800, 1 in 1000. It’s a very specific and narrow disease. When you take every child who has language retardation or every child who’s awkward in social interaction and you call that child autistic — 1 out of 80? That frightens mothers. And in this news report, notice: Nothing, just “We have an epidemic of autism,” as if this were avian flu!
Jerome Kagan is giving me a very serious look right now. I take your point about the media’s role in all of this, and that loops us back to this issue of context. But also, I should note that the DSM-5 may actually have a radically rethought definition of autism. I hate to leave it on this note, but I have to; you’ve opened up a can of worms on that, but the book overall is extremely thought-provoking.
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