Tuesday, November 27, 2012

Change: Continuous and Discontinuous

Recently I have several patients who have made remarkable progress in a short time. I would call this discontinuous change. That is, there is a prevalent notion that change occurs gradually, step by step. And sometimes that's how it happens. But then there are times when people change in multiple ways, on multiple dimensions, all at once. Change can be continuous or discontinuous. Now, in some ways this distinction requires some kind of arbitrary decision about what those terms mean. Ultimately, it's an issue of measurement. So, "continuous change" occurs at a smaller scale than the current measurement can detect, while "discontinuous change" occurs in a way that is distinct, a detectable change. Or, one could define it quantitatively or qualitatively. For example, "discontinuous change" could be defined as a change of a certain magnitude, or changes of a certain magnitude on multiple levels or in multiple scales.

But clinically, there are times when I'm simply blown away. A patient comes in who is hardly recognizable, and not simply because of cosmetic or clothing or grooming changes, although they may be a part of it. It's more that a different person walks through the door. Someone who thinks, speaks and otherwise behaves in multiple ways they have not previously. This happens with both substance use disorders and with psychiatric disorders. All of a sudden, everything is different. And no one, least of all the person who just transformed, has any idea why this happened now, at this moment in time. These events are not predictable with current knowledge and scientific methods. They may never be. (A part of me hopes and, of course, therefore predicts, that they never will be.) Anyway, in the past several weeks I have been completely blown away by progress in some of my patients.

What causes the change? There may be environmental events that have powerful effects, such as a DUI, hospitalization, serious medical illness, interpersonal experience, and so on. But these are not very reliable predictors and are not always present. I have patients who have had a DUI and then stopped drinking, and I have others where it doesn't seem to make a difference. Most often, my changed patients report to me that they have either "gotten sick and tired of being sick and tired," or "just decided," or "I just woke up and felt different." We don't have insight into how or why we make the most important decisions in our lives. Our reasons, by and large, are constructions designed to continue a cohesive narrative of our lives. We decide and then construct the reasons. Now sometimes it is the other way around. A slow, rational deliberation (System 2 in Daniel Kahneman's scheme) often plays an important role. But more often I think it's the other way around.

Here's my working hypothesis: complex dynamical systems (including us) tend to configure into a number of discrete, finite states, rather than an infinite number of slightly different ones. We tend to flip from one state to another, much like a tornado suddenly forms out of a certain set of optimal circumstances (but not always, and not easily specifically predicted.) And for us, these states include cognitive, affective (emotional), perceptive, behavioral, genomic, metabolomic, organ, organ system, organismal and social components that may all change at once on multiple levels.

And the thing is, there is only one thing happening even though it is happening at multiple levels. This is a hard one, an idea I finally developed when I was at NIH. In complex dynamical systems, an event occurs on many levels at once. Of course, there may be an instigating event, let's say an adverse social interaction that sets off a crusade of processes ending in severe depression and extremely heavy drinking. The response of a particular person (organism) involves all different levels of analysis essentially at once, because there are millions or billions or trillions of extremely rapidly interactive events that make up the whole. Everything happens on all levels at once: from particle physics up to global and beyond. However, we cannot examine the whole, we need to examine a part of it. We may talk to the involved person, ask them about their experience, perhaps ask them to fill out some scales. We may examine their social interactions and networks, or patterns of communication. We might put them in an fMRI or PET scanner to examine brain blood flow and metabolism, we might measure the output of a stress hormone such as cortisol in the blood, and so on. But we delude ourselves if we think that by looking at one level of analysis, we can say much about the system's behavior. It's not simply linear: A causes B which causes C. It requires a different type of mathematical modeling to help predict the behavior of the system as a whole. But this science is new and will take a long time to mature.

What about therapy or treatment? Sometimes, I think that by creating a safe, therapeutic environment and providing straight, often difficult, but always compassionate feedback, I may make a change like that possible. It often feels like a lifeline - I provide a secure support and anchor for taking chances and making changes. Some patients volunteer this information - that having me in their corner allowed them to make changes they were previously afraid to make, or that I provided a direction they had not seen before. Other times, I have no idea. A patient changed suddenly to the better, and I don't feel I had much if anything to do with it. This isn't false modesty; I'm talking about people I may see every 3 months for medication checks, but who suddenly undergo a big positive change. Most of the time, it's pretty hard to tell. Maybe I made a difference, maybe not. But it's enough to keep going, doing my best, trying to help people in any way I can. And I'm grateful for that opportunity. People let me into their lives in the most intimate ways imaginable, trusting me not to betray them, not to hurt them. I feel very privileged and humbled by that trust and I do my best to be deserving of it.



  1. I have many things I want to say regarding this post, but at this time I will keep it simple. The post reminds me of "The Doctor's Opinion" in Alcoholics Anonymous, see page xxxi, "About one year... Also, in Appendix II, Spiritual Experience, pg. 567 the writings of William James are used to speak of two types of spiritual experiences, which in my mind is perfectly in line with your comments about discontinuous and continuous change. Your post's theme, as I see it, is a wonderfully complex definition of what many would call a spiritual experience.

  2. Another thought(s)/question(s) comes to mind regarding discontinuous change versus continuous change. Can discontinuous change exist without maintenance, or a sustaining continuous change process? Is the discontinuous change you are seeing so profound that one is permanently altered/changed without need for the alteration of usual environmental homeostatic processes that are involved with the usual continuous change process clinicians are most familiar with? Does the discontinuous change have such a dramatic internal effect that externals also become radically changed, or is it that externals no matter how reinforcing of maladaptive processes cannot affect the dramatic change one experiences? In my mind discontinuous change cannot be maintained without some kind of follow up continuous change process(whether done within the clinical realm, or personal) that in essence maintains the change. I think I am attempting to debate that discontinuous change cannot exist without continuous change. Any thoughts, anybody?


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