Tuesday, March 31, 2015

GermanWings Airline Disaster: Thoughts on self-disclosure of mental illness and workplace violence.

Petra Kottsieper, Ph.D.

Almost everyone has likely heard about the air crash of a Germanwings flight 9525 en route from Barcelona to Duesseldort that occurred on March 24, 2015. It is now clear that the co-pilot deliberately steered the plane into the French Alps in order to kill himself and the other 149 passengers on board.  This has obviously resulted in frenzied search for a motive, which may at least explain what would bring a person to the point of committing such a heinous act.
Recently we have learned that the First Officer Andreas Lubitz had received treatment for possibly serious depression, suicidality and anxiety issues in 2009, resulting in a time of absence in his flight training.  He was subsequently declared fit for duty, resumed his very rigorous training and had passed all fitness tests since.  This has caused a lot of speculation about his mental health and a possible recurrence of more acute symptoms, as well as calls for more screening of mental health issues in pilots and flight crew.

As the investigation continues, we have learned that Mr. Lubitz had undergone diagnostic testing at a hospital for vision problems. This problem seems to have been diagnosed by one physician as psychosomatic, likely related to experienced stress and some underlying mental health concerns and/or psychological problems. Of course a vision problem, both medically based and psychologically based could be a major career ending problem. Doctors may have declared him unfit for duty at the time of the crash, however this information was neither passed on by Mr. Lubitz to his employer nor did he apparently follow the instructions of physicians.  Of course this would have required Mr. Lubitz to disclose to his employer that he was “stressed”, had vision problems that were thought psychological in origin, and had been declared unfit to fly.  His decision not to follow any of these recommendations had horrendous consequences. The research and opinions presented in the rest of this blog is not presented to excuse his behavior or decisions, but attempts  to highlight some of  the complex issues that surround this tragedy and think about ways to proactively respond to one of the larger issues at hand in this tragedy, the issue of self-disclosure at work . 

Why do people not disclose at work?
A review of the academic literature indicated that disclosure of mental health concerns in the workplace is most often associated with wanting to be a role model for others, requiring accommodations, a need to be authentic and honest (especially with coworkers), and to reduce the stress of concealing important parts of one’s identity. However, individuals who disclose are a minority.  A large majority of employees across various employment sectors do not disclose their mental health concerns and/or histories. Employees report fearing discrimination such as losing their jobs, being treated differently by employers and colleagues, having their competency questioned, being gossiped about and rejected due to being perceived as “different.” Sadly, there are good reasons for this fear, as 7 out of 9 research studies revealed discriminating hiring practices against people with mental health problems. For example one study cited, showed how applicants with a diagnosis of depression and anxiety were rated as significantly less desirable for hire when compared to people with disclosed medical disabilities and no disabilities.

 In the US and Europe legislation exists to protect people with mental health concerns from workplace discrimination. However, many people do not believe, apparently accurately, that these protections, will protect them.  So many employees choose to not disclose or to more actively conceal their “hidden” or “invisible” identities. This is an identity management strategy, very much the same as the strategies  used by people for other identities that can be kept “hidden, such as one’s sexual identity or HIV status. 

National rates of Depression and suicide:
It has been estimated that in 2002 the lifetime prevalence of major depressive disorder was 16.2% (32.6-35.1 million US adults) and for 12-month was 6.6% (13.1-14.2 million US adults). The same study noted that 10.4% of these individuals reported mild, 38.6% moderate, 38.0% severe, and 12.9% very severe symptoms. Respondents in the severe and very severe symptom categories reported that they were impaired in both their social roles (43.4% severe or very severe) and less so in their abilities to carry out their jobs (28.1% severe or very severe reported work domain problems).

It is know that approximately 90% of individuals who commit suicide either have been treated or could have been treated for some mental health condition, most often depression. Factors that increase suicide risk are the experience of desperation, hopelessness, anxiety, or rage.

Murder -suicide and workplace violence:
The Violence Policy Center (VPC) reported that in a six month period in 2011 approximately 313 murder-suicide events were reported in the media , resulting in 691 murder-suicide deaths, of which 313 were suicides and 378 were homicides. The majority of the perpetrators were male and their victims’ intimate female partners.  Often murder-suicide seems to occur after a breakdown in the relationship and/or within a framework of domestic violence. The media has reported that Mr. Lubitz long time off and on again girlfriend was not only pregnant but may have also broken off the relationship with him just a day prior to his actions.

What is clear and has not been talked about a lot in the media is that Mr. Lubitz actions constitute workplace violence, or a so called workplace rampage incident.  He committed it while employed, during his work hours and against his coworkers and employer, in addition to the many other victims on the plane. The main difference is that workplace rampage events are usually committed with firearms and not an airplane.  It has been pointed out by scholars that workplace shooters not only target individual people but also institutions, just as a school shooter does. A comparative case study pointed to similarities between suicide terrorists and rampage, workplace, and school shooters who also attempt or commit suicide. Rather than finding large differences between these groups, he found many similarities of risk factors between these groups, albeit to differing degrees. Preceding the attacks, these individuals experienced personal problems, including social, family problems, work or school problems, and precipitating crisis events. Workplace shooters were the most different from the other groups in that they experienced fewer family problems prior to their attacks. Their attacks were also more often linked to specific trigger or crisis events such as being fired, or reprimanded by their employers. Suicide notes were less often present in this group and Lankford suggests that the workplace shooter “may be the most normal of the four types of attackers in this study, from a cultural, motivational, and behavioral standpoint.”

What does all of this have to do with the GermanWings Disaster?
Suicidal individuals who commit workplace or other rampage killings may not fit into what many people typically think of when they think of a depressed person.  While an underlying or more acute depression may very well be present in some of the people and then obviously plays some role, it is not the only causative explanation as outlined previously.  Work problems such as a loss of work or in Mr. Lubitz case a fear of losing his job over his eye condition or having to reveal his recurrent psychological problems may have been a contributing factor. He may have also experienced a significant interpersonal problem if his girlfriend dissolved their relationship. Trigger events are one of the hallmarks (and few) predictors in rampage and workplace violence murder-suicides. These trigger events may also increase hopelessness and increases in anger or rage, and/or a need to make some kind of statement in order to gain some type of notoriety.

In addition to undisclosed and likely untreated (current) depression, an inability to tolerate a fear of failure or handle rejections from significant trigger events, people that commit acts of rampage killings or workplace rampages may also have certain personality dispositions in addition to all the other risk factors. They may be more self-centered, display a lack of empathy for others, or at times even evidence some paranoid thinking.  We just do not know enough about Mr. Lubitz’s personality disposition, except unconfirmed reports that he was very controlling with his girlfriend.  

What does this mean for employers and people with depression and other mental illnesses?
This is an unspeakable tragedy which will warrant a response for how workplaces handle employees with mental illness. We need to remember that events like workplace rampages are still very rare, especially in European countries.  We also need to remember that depression, anxiety or even suicidality alone may result at times in a need to take time off from work when someone’s competency is affected, but that violent actions will not be prevented by an increased focus on dangers of “mental Illnesses.”  If we want to increase our screenings to better predict or prevent workplace rampage or workplace violence incidents we need to screen for the risk factors of the specific and diverse types of workplace violence that exist, and not just increase general screens for depression and anxiety. 

We want to encourage more individuals TO disclose their mental health problems to their employers in order to receive support, accommodations or time of if needed. Similar to when someone with an acute flare-up of a chronic medical illness can take off without fear of losing their job or having their competency questioned. We will only reduce passive and active concealment if we reduce stigma against these conditions and not when we increase it. Successful murder-suicide prevention, or in this case a rampage killing, relies to a very large degree on knowing what is going on with the person in their workplace, and personal life domains. Increases in non-disclosure are neither helpful nor desirable. 

Final thoughts

I have obviously no idea what Mr. Lubitz was thinking that drove him to such a terrible conclusion to his young life.  I cannot imagine the anguish, pain and anger of the families of the people that were killed by him and likely the parents and/or other family members of Mr. Lubitz. I hope there will be more answers for the families and all of us in the days to come, but I doubt those answers will be straightforward and not multiply determined.   I also hope that employers will continue to work on creating more welcoming workplace environments for people with mental health problems by actively promoting the inclusions of individuals with mental health issues into their workforces and providing support when needed or requested. 

Thursday, March 26, 2015

Understanding Anorexia

Stacey C. Cahn, PhD explores causes and treatment of anorexia nervosa, the most dangerous eating disorder.

Eating disorders are serious, debilitating conditions associated with significant morbidity and mortality, and distress. Anorexia nervosa, in particular, is associated with the highest mortality and suicide rates;  compared to healthy peers, women with anorexia are up to 12 times more likely to die of any cause, and approximately 57 times more likely to die from suicide, over the same period of time. 

The best predictor of positive treatment outcome in anorexia nervosa is early detection and intervention. Those suffering from eating disorders often feel shame, isolation, and face stigma. Children who experience anorexia may have difficulty understanding, much less explaining, their symptoms.  Others may not want to let go of perceived “benefits” of their eating behavior. So, for a variety of reasons, many suffer in silence and secrecy, which can serve to dangerously delay intervention. 

What causes some people to develop anorexia?
First, it's important to recognize that there is a genetic component to anorexia.  Someone with a first-degree relative who's had anorexia is at much greater risk for anorexia than someone without a family history.  So individuals have varying levels of biological "predisposition" to anorexia.  Other risk factors fall into two categories:  1) risk factors for psychiatric problems in general, including anorexia; and 2) risk factors specific to anorexia.  
General risk factors include low mood, a history of physical and sexual trauma, general family problems, and a parent with a psychiatric disorder.  These all appear to increase one’s risk for later mental health problems, including eating disorders.  
Specific risk factors for anorexia include: being female, age (early-mid adolescence is the prime time for onset), perfectionism, and concerns about shape and weight (and subsequent dieting).  Shape and weight concerns may be intensified by participation in competitive sports such as gymnastics, track, swimming or dance, where shape and weight are often related to performance.

Why is anorexia more prevalent in women? 
We don't really know for sure. Anorexia is relatively uncommon—historically, only about 0.3 percent of the population suffer from anorexia.  (Recently, however, the American Psychiatric Association has broadened the diagnostic criteria for anorexia nervosa slightly, so the official prevalence will likely rise somewhat.) Of those who suffer from anorexia, only about 10 percent are male; it's hard to get good data on a population that small. It does seem that cultural factors at least partially explain this gender discrepancy; thinness is more central to our culture’s “feminine beauty ideal;” there’s not an equivalent standard for men. Accordingly, men, overall, have less dissatisfaction with their bodies, and are therefore less likely than females to diet for weight loss, even if they are overweight. This disparity is significant because body dissatisfaction and dieting are risk factors for anorexia.

Are there any promising new treatments in development? 
Anorexia nervosa is notoriously difficult to research and treat. Treatment effectiveness has generally been disappointing due to a host of factors including the ambivalence about recovery intrinsic to the disorder.  

One psychological treatment that seems particularly promising is Enhanced Cognitive-Behavioral Therapy (CBT-E). Oxford University psychologist Christopher Fairburn and his colleagues have made impressive strides with their recent treatment research in Europe; they’ve conducted rigorous clinical trials testing CBT-E for adolescents and adults with anorexia. Compared to earlier treatment outcome studies, a remarkable number of those who completed the treatment had maintained their gains sixty weeks after treatment. Still, the most important predictor of positive outcome in anorexia is early identification and intervention. In general, the longer the duration of illness before treatment, the worse the prognosis.

Understanding that vaccines do not cause illness

Jessica Glass Kendorski, Ph.D., NCSP, BCBA-D

Vaccination—the word has become quite divisive. On both sides, we find well-meaning, intelligent, good parents who just want what is best for their children, and to protect them from harm. The science behind the benefits of vaccinating are clear (see this Healthy Kids blog about the importance of herd immunity), and the recent measles outbreak shows the consequences when individuals do not vaccinate. The total number of cases is up to at least 155 cases in 16 states. Over the weekend, New Jersey became the latest state to join the list.

So why are well-meaning, intelligent, parents, putting themselves and their children at risk? Part of the reason is because many people have not personally experienced the devastation of some of these viruses for which we now have vaccines, causing them to underestimate the seriousness of illnesses like measles. But there’s another factor in play: a natural, predictable bias in the way humans are wired to think, a bias known as the post hoc fallacy--the natural tendency for us to see causation in two events that co-occur in time.

The post hoc fallacy, fully named “post hoc ergo propter hoc” translates from the Latin “after this, therefore because of this.” It is an error in logic to assume that if event 1 occurs right before event 2, then event 1 necessarily caused event 2. As a personal example, my daughter received her booster MMR vaccination when she was 4 years old. The very next day she developed a rash and spiked a 104-degree temperature. I was scared, but, fortunately, it was clear to me that this probably wasn’t because of the vaccination; her 2-year old brother had had the same rash and high temperature a few days prior, and had been diagnosed with the Hand, Foot and Mouth virus. It would have been natural for me to blame the MMR vaccination for her illness (since one occurred right before the other), but I had the “benefit” of having another kid in the house with similar symptoms who 1) had been diagnosed with a highly contagious illness, and 2) had not been recently vaccinated.

Young kids get sick with regularity.  Young kids get vaccinated with regularity. Therefore, there is a reasonable chance that your child will get sick some time after receiving a vaccine, without the two events being related.  Similarly, with Autism Spectrum Disorder, symptoms begin to emerge around the same time that toddlers routinely receive the MMR vaccination. This timing predictably causes some parents to question whether the vaccination caused the disorder, when there is no evidence that suggests the two are related, and substantial evidence supporting that the two are unrelated.

This tendency to equate causality with timing has long been shown in the behavioral science literature. Take B.F. Skinner’s experiment with pigeons. The birds would receive a food pellet at random intervals from a machine. After a certain amount of time, they would perform whatever random activity they had done before receiving the pellet, as if that action would produce it. This is exactly why humans strive to understand what happened —what they did—to cause an event. And, it’s the reason why so many parents are convinced that a particular vaccination can cause an injury or disorder, when in reality, the two are unrelated.

If we want to increase the number of people who vaccinate their children, explaining the science is not enough. We must understand the natural tendency for people, all people, to equate coincidence with causality. We must recognize the stories that people tell about their child getting sick are very real, and very heartbreaking. We must help people understand the fallacy in their logic; that just because two things occur together does not mean that one caused the other. Any successful message has got to include real empathy.  Empathy for these very, well-intended parents, who have only the best interest of their beloved children at heart.  

Why we shouldn't physically punish our kids

Jessica Glass Kendorski, Ph.D.,NCSP, BCBA-D

The recent arrest of Minnesota Vikings Running Back Adrian Peterson has sparked a divided reaction within the NFL around the use of physical punishment with children.

Peterson’s lawyer, for example, said that Peterson “used the same kind of discipline…that he experienced as a child.” Former basketball player and current NBA analyst Charles Barkley also defended Peterson, while ESPN’s Chris Carter (a former Viking himself) noted, “You can't beat a kid to make them do what you want them to do." This range of reaction echoes the national debate surrounding physical punishment. But, existing research tells us that Carter is right.

Researchers define physical punishment as “the intentional infliction of pain and discomfort and/or the use of force to stop or change a behavior.” A 2008 study on the effectiveness of physical punishment on children in the U.S. found no long term effects on behavior change; essentially, when the threat of punishment was gone, the negative behavior returned.

Additionally, there is extensive research that physical punishment puts children at substantial risks for future defiant and aggressive behavior, increased mental health concerns, as well as greater risk of serious injury and abuse. Recent brain science research has shown that harsh physical punishment may actually have detrimental effects on the development of a child's brain.

The negative effect of punishment, physical or otherwise, extends to our schools as well. Many schools adopt “zero tolerance” policies, but in order for those to work, educators must discipline students in harsher ways, often with little effect. The US Department of Education reported in 2011 that there were more than 3 million suspensions per year and over 100,000 expulsions. What’s more, consistent use of punishment in schools causes children to become fearful and avoidant of school and teachers, and interferes with positive, pro-social relationships. Brain science is showing us that warmth and nurture are essential to brain development. Academic success—one of the best indicators of adult success—is best achieved in a school climate that is warm, welcoming, and promotes positive behavior and positive interactions with adults and peers.  In order to reduce the use of physical punishment, we must have other options.

Children learn to behave when their parents notice and respond to their behavior appropriately. When a child misbehaves, it is essential that parents remain calm (provide appropriate time outs if necessary) and communicate the appropriate way to get it right next time.  Techniques such as teaching behaviors that you want to see (keeping your hands to yourself and why); Reinforcing specific behaviors (keeping your hands to yourself); Modeling appropriate behavior (parents keep their hands to themselves); and reinforcing a low preferred behavior (doing homework) with a high preferred behavior (playing a game) are effective ways to encourage appropriate behavior.

The risks to physical punishment are huge and well outweigh the short term reduction of a negative behavior. It's time to change the culture of discipline in our country, and to show parents that there is a better way. Rather than debate its effectiveness (the research is clear on that), let’s educate on its tremendous risks, and on more positive approaches to discipline. It is not too late to change our educational and parental discipline practices. Our kids deserve better.