Who's Fooling Whom?

This is a story about how a solid understanding of research methodology and an intelligent application of a basic psychoanalytic concept led to the discovery of a significant flaw in the conception and measurement of mental health in the scientific research literature. It is also a tale that underscores the importance of inserting trained psychoanalytic clinicians into the research equation to develop clinically relevant science.

In 1993, a controversial research report called “The Illusion of Mental Health” appeared in the American Psychologist. The article, written by psychoanalytic psychologists Jonathan Shedler, Martin Mayman, and Melvin Manis, criticized the widespread research practice of relying exclusively on self-report inventories to test hypotheses about psychopathology and its amelioration.

Self-report instruments are ubiquitous in psychological research. They are easily standardized, relatively inexpensive to administer and score, and do not require a skilled clinician to interpret. A typical self-report contains several face-valid statements that identify different aspects of a state of mind or a character trait. (For those not familiar with this term from measurement theory, a statement is said to be face-valid when that statement seems to measure what it logically intends to.) Research subjects indicate whether or not a statement is self-descriptive. An index of the subject's mental health is then configured, based on the ratio of self-descriptive to non–self-descriptive items. Examples of statements from the most well known inventories of this type are “I feel I am a complete failure” (Beck Depression Inventory) or “Have you ever wished you were dead?” (Eysenck Neuroticism Scale).

Armed with a psychoanalytic appreciation of the role of defense in the development of illness and the preservation of health, the Shedler team argued that while the self-report measures could recognize distressed persons, even the best of these objective assessment devices couldn't identify persons whose claim to be mentally sound was premised on their denial of mental disturbance. If Shedler and his colleagues were correct, scientists were using a procedure that systematically misidentified certain research subjects as healthy when they were not. Consequently, the results of “thousands of published findings that rest on self-report measures of mental health” might well be in doubt.

The predictive accuracy of the self-report inventory was therefore reduced, and the meaning of mental health distorted. As Shedler, Mayman, and Manis concluded, the self-report inventory is a valid measure of health only when subjects indicate that they are distressed. It cannot differentiate between someone who is actually healthy and someone who falsely believes that she is. It cannot discern mental health from its illusory counterpart.

To demonstrate the empirical validity of their analysis, Shedler et al. had two psychoanalytic clinicians, unaware of all other data, interview 132 adults about their early memories and the impressions of themselves and others derived from these memories. This interview procedure was the basis for clinical judgments about subjects' mental health. Subjects also completed a Beck Depression Inventory or an Eysenck Neuroticism Scale and were then subjected to an anxiety-evoking competitive performance task, during which heart rate and blood pressure were assessed.

The findings confirmed the importance of including trained clinicians as part of a research team. Not only did the research clinicians reliably differentiate the “defensive deniers” from “genuinely healthy” and the “manifestly distressed” subjects, but also the defensive deniers were found to have elevated coronary reactivity during the stressful competitive performance task that was both statistically and medically significant.

Science is self-corrective. As findings like these are recognized by the scientific community, it becomes progressively more difficult to exclude psychoanalytic hypotheses and psychoanalytic clinicians from the research workplace. Shedler, Mayman, and Manis have shown the importance of one psychoanalytic contribution to science by identifying the mental health illusion.