shrink tank

welcome to my blog

Posted in autobiographical by Jim on June 25, 2014

I’m a psychologist, and I post here from time to time. My private practice profile is at http://therapists.psychologytoday.com/rms/82571.

You can also find me at ResearchGate: http://www.researchgate.net/profile/James_Sturges2.

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values

Posted in joie de vivre, psychology, raison d'être, relationships by Jim on June 9, 2016

Attitudes (some might say values) are the essential ingredients that inform my strategies in specific situations. For example, when I meet someone, an attitude of curiosity informs the way I interact. I am interested in knowing that person, so my behavior will flow from that motive. Merely using a script is inadequate in comparison, because it lacks interactivity, intensity, and active listening.

An attitude of service orients me to opportunities of meeting others’ needs. My external focus and lack of egocentricity will enable me to be undaunted by events that would otherwise disable me.

Passion for purpose pulls me to continue hard work, and contributes to an ability and willingness to persist in the face of adversity. Although it is sometimes hard to know one’s purpose, and I at times change my mind about what mine is, exercising strengths in purposeful activities is fulfilling. Cultivating passionate enthusiasm for doing so transforms my life from mundane into exciting.

A radically non-defensive attitude enables me to seek the feedback that fuels continuous improvement, and nurtures relationships.

tim o’brien’s books

Posted in writing by Jim on February 17, 2016

The Things They Carried, by Tim O’Brien (1990), has both a literal and metaphorical title. It refers to both the gear and the preoccupations that soldiers carried as they humped it down the trails of Vietnam in 1968 and 1969. The writing merged with the thoughts of the characters at times, filled with self-blame and ruminative repetition of detail, and dialog was not set off with quotes. The book was hard to read at times, because of the gore depicted, and the occasional cruelty of the young men trying to cope with it all. A reward for the reader, though, is the depth of O’Brien’s insights. In his analysis of the crisis he experienced in being drafted, he characterized his compliance with the draft as less courageous than dodging it would have been. He noted that soldiers often go on dangerous missions simply to avoid the embarrassment of refusing. In justifying a blend of fact and fiction, he argued that accuracy of detail is less important than capturing “truth,” and furthermore, that true war stories have no moral. There was a meta-narrative about his writing choices. At times this interfered with suspension of disbelief, but was instructive.

The book was about relationships, with the living and the dead, and about coping with trauma, primarily by creating stories. It was a brilliant commentary on the ways soldiers engage in story-telling, and why they do: “When I take a high leap into the dark and come down thirty years later, I realize it is as Tim trying to save Timmy’s life with a story.”

Tim O’Brien’s (1969) If I Die in a Combat Zone, Box Me Up and Send Me Home was more of a nonfiction journal of his Nam year than The Things They Carried, with only “names and physical characteristics of persons…changed.” It conveyed the culture of the late 60s, yet the Vietnam war was in some ways similar to war today, and O’Brien certainly provides us insight into war.

Co-written with N. Cho

adaptability

Posted in psychology by Jim on October 30, 2011

I’m very interested in forgiveness, including the forgiveness-related work of Fred Luskin (http://learningtoforgive.com/) and Everett Worthington (http://www.people.vcu.edu/~eworth/). In a nutshell, forgiveness involves empathy. People are often not ready to forgive, but choosing to do so is for one’s own benefit, not for the benefit of the other person. It facilitates an unburdening. There are a number of exercises that Luskin and Worthington suggest, including re-writing the narratives of what happened in a way that sticks closer to the facts and avoids the attributions that we make that involve malice on the part of the other person. I strive to make benevolent or at least benign attributions about the actions of others. If I can’t seem to do that, then I assume that if I had been in the other’s shoes and lived his or her life, I might well have felt or acted as he or she did. I work at this every day; it is a constant challenge. Luskin also incorporates breathing, relaxation, and imagery exercises, and he suggests that we begin our forgiveness work by “forgiving ourselves, and other people we like.” I have a previous brief blog post about Luskin’s ideas at https://jimsturges.wordpress.com/2010/05/06/forgiveness/.

When I was at Kelly Wilson’s workshop at a mindfulness and acceptance conference about a week ago, we abandoned our problem-solving mode for a bit and practiced simply being present with each other while discussing early experiences of things we did not like about ourselves. Part of what happened in those moments was the cultivation of understanding and compassion that was incompatible with anger. Compassion for ourselves, and compassion for others.

Yesterday I attended an all-day seminar by psychoanalyst Martha Stark, which came at all of this from yet another perspective, and was really intriguing. Stark talked about “relentless hope: the refusal to grieve,” and “relentless outrage.” She described patterns in which we are faced with disappointment from others, and instead of adapting to it, we often maladaptively and persistently keep trying to get what we want. This is a defense mechanism, in that it is a reaction to stress that we are not ready to cope with.

When the parent leaves the infant alone briefly, the infant loudly protests. Over time, and repeatedly experiencing the reliable return of the parent, the infant begins to learn to self-soothe during the absences. When the unmet needs are too traumatic, however, the ability to self-soothe is overwhelmed, and defense mechanisms kick in. This may manifest in relentless pursuit of the object or relentless anger and hopelessness. There is a defensive need, it is traumatically frustrated and thus strengthened, but then eventually hopefully transformed into adaptive capacity. We become stronger at the broken places.

The therapist helps the client by both being supportive when needed and challenging when possible. The challenges involve interpretations that help the client to gain insight into the behavior, re-experience the feelings involved, and re-enact the earlier unresolved issues. This happens naturally, because therapist is inevitably less than perfect, as the parent was. The client reacts to this with characteristic defenses.

Stark formulated several models of therapeutic work. In Model I, the mode of therapeutic action is enhanced knowledge. The therapist and client work through resistance to gain insight. Resistance is the defensive reaction. Over time, with more insight and knowledge, a more thoughtful and reflective response develops, and the client becomes more aware of the dysfunctional dynamics.

In Model II, which we shift in and out of, we listen empathically. We adopt the client’s affect. We share the experience. In Model I we are opaque, not bringing ourselves into the interaction. In Model II we bring the best of ourselves into the room. The client as child needs to grieve deprivation. Ideally this results in structure, internalization, an adaptive ability to handle grief within. If it is too overwhelming, defenses can include narcissism or a stereotyped posture of shame or disappointment such as, “I knew no one would like me.” Model II is about acceptance of the object as “separate, limited, immutable.” It cannot be controlled even though we want to control it and may relentlessly pursue trying to make over the object into what we want.

The same dynamics get co-created again and again to allow this re-enactment. Stark quoted Warren Zevon: “If you won’t leave me, I’ll find somebody who will.” In Model III, the therapist is engaged in an authentic relationship with the client (whereas model II is for the client). As therapists we strive for “benevolent containment” of the “toxic mud balls” that the clients give us. The internal yearning that has been traumatically frustrated is displaced onto the therapist. The client has found a new bad object. “The therapist brings to bear her own ability to adapt: benevolent containment of toxicity.” The therapist has the capacity to relent. Together with the client we repair the disruption in the relationship. The bad becomes good. What were knee-jerk re-enactments become structural change.

We repeatedly have to come back and join with the client. In those instances it is not about what we think, it is instead expressions such as, “it just hurts so bad.” We are listening with every molecule of our being, and the clients go ever deeper, as Stark puts it. They lead the dance and we follow. In Model III we “stay centered in self and take in their stuff.” It is a “co-created story.” The story is “about there and then and also about here and now–the therapeutic relationship.” Part of all of this is accountability. That is, we have to look at what we have contributed to the transference and hold ourselves accountable in an honest way. This is echoed by Yalom and others.

We “challenge when possible and support when necessary, so they can re-organize at a higher level.” Our interpretations are anxiety-provoking, and have to be done in the right amount with adequate support. Like sands in the hourglass, minor avalanches of stress contribute to the reconstitution of the pile. This optimal stress helps the patient to go back and forth between reality and the experiences she finds herself having. We provide “conflict interventions,” such as “You do know that he’s gone, but you find yourself still hoping.”

To work through resistance clients first come to understand how they create the situations and how they gain from them. They know that they need to let go, but they so desire what they want that they engage in masochistic hope, or they lash out in sadistic outrage. As therapists, our response to their outrage toward us should be, “How did I fail you?” They often think we are being critical, and set us up to be so; that’s what they know. Yet being too loving is perceived as controlling. We must allow ourselves to be turned into the bad object (projective identification), and even take responsibility for our part in all of it: We relent. However, we also challenge: “How did you imagine that I might respond?” Or, “You are really angry, but you know that if you’re ever going to get better, someday you’re going to have to slow down and give someone a second chance” (!).

At the end of the day, Stark shared a touching story in which she described a re-connection with her mother, who had disappointed Stark in her childhood, by never being that into parenting. This re-connection was essentially facilitated by compassion for her older, frailer mother, and appreciation for the good qualities that her mother did have–forgiveness by Stark involving empathy, acceptance, and adaptability.

laughter and tears at a mindfulness conference

Posted in psychology by Jim on October 22, 2011

We laughed a lot during the morning talk at The Arts of Mindfulness & Counseling Series in La Jolla, because Scott Miller was an animated, highly engaging, and hilariously funny entertainer. He talked about research on outcomes in psychotherapy, and the work of K. Anders Ericcson and others on expertise (recall Malcolm Gladwell’s 10,000-hour rule, based largely on Ericcson’s work). It turns out, of course, that we need to do more than practice. We need a lot of feedback along the way, so we better realize that we need it. Studies show, however, that we psychotherapists all think we are above average, as do people in other professions (especially college professors). We consistently overlook treatment failures. We are so focused on doing well, and striving to avoid mistakes, that we do. Or so we think. In actuality, there is tremendous variability in effectiveness across clinicians. The good ones, as it turns out, are error-centric. Miller and colleagues provide ways to measure outcomes of clinicians, and have also interviewed the ones that are very good. These “supershrinks,” as Ricks (1974) first labeled them, carefully elicit client perceptions of problems in the therapeutic relationship and its effectiveness. These therapists are very focused on their errors and correcting them. One therapist, after receiving a 2 mm lower rating on a visual analog scale regarding the therapeutic alliance, had extracted information from the client about what was wrong, and then practiced repeatedly in front of a mirror to learn how not to use a certain facial expression. She believed, by the way, that she was not that good of a therapist, and thus had to work very hard at improving. She would annoy her colleagues because she frequently called them to get help in figuring out what she (not her client) was doing wrong, when things weren’t going well. This focus on deliberate practice of the tough parts of an activity turns out to be the key in other fields as well. It is true for super athletes and super musicians. Miller played some video of child pianists Roger Shen and Rachel Hsu. In the video Rachel plays the violin, her other instrument, at a breakfast prior to her formal performance, to get more practice and to watch her audience. Miller said she later brought some of the audience to tears as she played Franz Liszt’s incredibly difficult Un Sospiro, in which the pianist’s hands must repeatedly cross. When asked about her amazing talent, she replied that it is not talent, but hard work…four hours a day including weekends, vacations, Christmas and her birthday.

Miller stressed that we have to have some way of measuring how we are doing (know our baseline); we need to get formal and routine ongoing feedback and compare it to norms; and we need to engage in deliberate practice. We have to overcome automaticity, and work hard to develop the highly contextualized and deep domain-specific knowledge that allows us to see things that others can’t: Like the NICU nurses who can see infection before the bloodwork comes back, or the baseball players that adjust their fielding positions before the ball is in the air.

The tears came in the afternoon, as Kelly Wilson talked about how things will go horribly, terribly wrong, such as in the deaths of his brothers, the plight of the people of the Mississippi Delta, and in all of our lives. He was especially able to engage the audience when he asked us to imagine what we liked least about ourselves, and how long that that thing had been an issue. As we sat with eyes closed, we were asked to visualize and empathize with our young selves, and to communicate something helpful to them. In doing this activity, Wilson had collected lots of responses over the years, on index cards (from both lay and professional audiences). For some folks it had been bothering them as long as they could remember, and most people said it had been an issue since at least adolescence. Many had kept it to themselves all those years. He wasn’t sure what to do with all the cards, but his daughter had an idea. She made a video of them with her iPhone: A card or a few of them together were each shown for several seconds, set to music. As he showed the video, card after handwritten card said, “I am not enough,” or something very similar. What, he asked, if we all have a dark secret that we carry around, and it turns out it is the same secret?

Our brains evolved to do evaluation and comparison between bears and blueberry bushes, and it was safer to miss lunch than to be lunch. As we developed language we turned this evaluation and comparison device toward ourselves. But as therapists and humans we often must abandon our problem-solving mode of thinking, and simply behold the person in front of us, listening intently, trying to know and understand.

During a break, I talked with Kelly about my preoccupation, experiential acceptance self-efficacy, and he thought that I am on the wrong track (and being error-centric, I found this pretty riveting). He cited recent data that suggest that changes in self-efficacy (and cognitive content in general) are more an effect of than a cause of improvement in client functioning. Fascinating stuff.

experiential avoidance vs. acceptance

Posted in psychology by Jim on December 17, 2010

Much of applied clinical psychology is designed to help people reduce problems with depression and anxiety. Depression and anxiety involve negative feelings (affective states), thoughts (cognitive components), and somatic components. Because adaptive thoughts can be volitionally invoked, this has often been the point of intervention–many psychological interventions have been developed that help people change their thinking. Unhappy people are taught to think in more positive terms (cognitive restructuring). Psychological interventions have also been developed that encourage people to engage in behaviors that may reduce uncomfortable physiological arousal experienced as a part of anxiety. For example, people with anxiety are often instructed to enter and stay in (rather than avoid and escape) situations associated with anxiety for them, with the goal of allowing the anxiety to diminish. Cognitive restructuring and practiced physical relaxation techniques, such as deep breathing and progressive muscle relaxation, typically accompany these “exposure” efforts.

Even with research-tested approaches, difficulties can arise for a variety of reasons. The issue of client motivation has been a particular concern, and led to approaches such as motivational interviewing (helping clients resolve ambivalence and set goals[1]) and similar approaches (e.g., “paradoxical agenda setting” or “paradoxical inquiry”[2]), as well as harm reduction strategies (e.g., intersperse water and food with alcohol intake) that do not assume adherence to an ideal regimen. Additionally, special interventions have been developed for clients with very severe emotional symptomatology[3].

When treatment approaches do work, it may be due to factors unrelated to the theoretically effective components. Interesting findings have emerged in several treatment areas that suggest that benefits of treatment apparently may be tied in large part to the ability of the treatment to enhance the clients’ perceived control over problems, even when this does not involve actual control. For example, the use of biofeedback to reduce headache was shown to be effective even when false feedback was used. More broadly, so-called “placebo” effects are widely recognized, which enhance adaptive beliefs and in turn yield a variety of downstream benefits.

Closely tied to perceived control is the concept of acceptance. In stress management approaches, for example, problem-focused coping is augmented by emotion-focused coping. Whereas problem-focused coping involves attempted control over external stressors, emotion-focused coping enhances the ability to cope with negative affect. And although emotion-focused coping (emotional regulation) can involve increasing control over one’s emotions, it can also involve acceptance of undesirable situations and negative internal states. For example, some of the research on panic disorder that suggests that the difference between people with panic disorder and people without panic disorder is that although both groups experience unexpected and uncomfortable physiological arousal from time to time, the people with panic disorder become worried about it, and start taking steps to try to prevent another “panic attack”[4]. People with panic report difficulty accepting being upset, and a tendency to avoid unpleasant emotional experiences.

Acceptance of negative internal states has become an important tenet in newer cognitive-behavioral approaches[5],[6] such as Acceptance and Commitment Therapy and “mindfulness,” sometimes collectively called the “Third Wave of  Behavior Therapy.” These approaches are considered more compatible with the acceptance aspects of 12-step programs and spiritual approaches than are traditional behavior therapies[7]. Acceptance is a key part of 12-step self-help groups (i.e., “to accept the things I cannot change,” in the Serenity Prayer). Wisdom traditions such as Buddhism advocate acceptance in order to cultivate a peaceful state of being. Some protestant Christian groups have traditionally encouraged members to accept current difficulties with an eye toward the hereafter. Acceptance of negative affective states is typically a more adaptive approach than many alternatives, such as addictive behaviors or self-harm, and more effective than other methods of emotional regulation, such as thought suppression.

However, some meta-analyses have found that although therapies using acceptance are better than placebo or waiting list control groups, they are not better than established therapies at treating depression and anxiety[5]. This is not an unusual finding in psychotherapy research (the so-called dodo bird effect, attributed to nonspecific factors). However, in this case it may reflect that measures of acceptance have not been appropriately specific[8]. The most important (negative) factor may be unwillingness to experience negative internal states[9]. This is a fascinating area of study, with lots of promise, and lots of exciting findings already. The experiential avoidance-experiential acceptance continuum is proving to be a very valuable dimension in psychotherapy research.


[1] Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (Eds) (2007). Motivational interviewing in the treatment of psychological problems. New York: Guilford.

[2] Burns, D. D., & Auerbach, A. H. (1992). Does homework compliance enhance recovery from depression? Psychiatric Annals, 22, 464-469.

[3] Linehan, M. M., & Dexter-Mazza, E. T.(2008).Dialectical behavior therapy for borderline personality disorder. InD. H. Barlow (ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed.; pp. 365-420). New York: Guilford.

[4] Tull, M. T., Rodman, S. A., & Roemer, L. (2008). An examination of the fear of bodily sensations and body hypervigilance as predictors of emotion regulation difficulties among individuals with a recent history of uncued panic attacks. Journal of Anxiety Disorders, 22, 750-760.

[5] Powers, M. B., Zum Vörde Sive Vörding, M. B., Emmelkamp, P. M. G. Acceptance and commitment therapy: A meta-analytic review. Psychotherapy and Psychosomatics, 78, 73-80.

[6] Sauer, S., & Baer, R. A. (2010). Mindfulness and decentering as mechanisms of change in mindfulness- and acceptance-based interventions. In R. A. Baer (ed.), Assessing mindfulness and acceptance processes in clients: Illuminating the theory and practice of change (pp. 25-50). Oakland, CA: Context Press/New Harbinger Publications.

[7] Wilson, K. G., Hayes, S. C. & Byrd, M. R. (2000). Exploring compatibilities between acceptance and commitment therapy and 12-step treatment for substance abuse. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 18(4). Retrieved from http://www.springerlink.com/content/q8l117087428434k/

[8] Chawla, N., & Ostafin, B. (2007). Experiential avoidance as a functional dimensional approach to psychopathology: An empirical review. Journal of Clinical Psychology, 63, 871-890.

[9] Kashdan, T. B., Barrios, V., Forsyth, J. P., & Steger, M. F. (2006). Experiential avoidance as a generalized psychological vulnerability: Comparisons with coping and emotion regulation strategies. Behaviour Research and Therapy, 44, 1301-1320.

fascination facilitates learning

Posted in teaching by Jim on June 16, 2010

There is a great youtube video in which a woman named Amy Walker demonstrated various accents. She was brilliant, but especially so in a separate video in which she taught how to learn accents well: You must be fascinated in them, she asserted. If you are not, you will not pay attention to the accents, the speakers, and why they speak as they do. You will not observe, analyze, and practice. When she went on to describe five categories of an accent, she suggested that the listener start with the component he or she is most interested in, and add the rest later.

These ideas–the need for fascination with the material and the suggestion of starting study at the point of greatest interest–are exceptionally good advice. Learning does not have to follow someone else’s starting and stopping points. Once you have absorbed the stickiest knowledge, you have a framework with gaps to fill in, and filling in gaps is interesting because it resolves questions.

Intelligence involves curiosity and persistence, which are practically synonymous with fascination. This alone may be good reason to pursue what most interests you, and find the aspects of the material that fascinate you.

Amy Walker used another pedagogical strategy without mentioning it, by the way, and that was repetition. By the time you listen to the accents clip, you are not likely to forget her name.

crazy heart

Posted in psychology by Jim on June 8, 2010

Jeff Bridges was cast as an alcoholic country music artist in the 2009 movie Crazy Heart. The story involved a singer-songwriter’s slide toward death, and late redemption. He finds and loses the love of a writer played by Maggie Gyllenhaal, and having abandoned his own four-year-old son years before, he connects with her child of the same age.

The movie was strong on several levels: It portrayed alcohol dependence well. It dealt with fatherhood and psychological maturity. It had a theme of fulfilling one’s promise, or not, based on being able to cope and function adaptively.

When I was young, I thought there was honor in being a misfit. The idea of being a brooding, troubled rebel seemed romantic. With the counterculture as a backdrop, and an insistence on doing things my way, I saw little but hypocrisy in becoming part of what was called “the establishment.” Although I no longer idealize being troubled, I still find it a challenge to follow advice, make wise choices, have patience, and be disciplined. Crazy Heart made me think about these issues again.

forgiveness

Posted in psychology by Jim on May 6, 2010

Today I attended a talk on campus by psychologist Fred Luskin, director and co-founder of the Stanford University Forgiveness Project. Luskin repeatedly invoked the Dalai Lama’s assertion that his religion was kindness. Luskin advocated practicing kindness in small steps, starting with forgiving ourselves and “other people we like.” He knows that it is not easy, that we need to grieve first and that we need to protect ourselves, but points out that it works in even tough cases. For example, with six days of forgiveness-related work, he was able to show a 30% reduction in depression among mothers whose sons had been murdered.

Luskin pointed to the known cardiac benefits of positive emotion. He emphasized the power of the practice of gratitude on well-being. He discussed a happiness study that collected reports of thoughts and feelings at random times, which found a strong bias toward negativity. Ironically, people found things to complain about most of the time (70+%) pretty much regardless of what their experiences were. Luskin asserted that this is something we are wired for, because it is adaptive to be vigilant about danger and problems. He believes that although we cannot change that mandate, we are also wired for the “antidote,” which is “kindness, gratitude, and attention to good.”

We should therefore pay attention to the kind acts of others toward us, kind acts of our own (saying to ourselves, “this is what love is…”), and be mindful of the beauty of our surroundings and the miracle of being alive. He teaches diaphragmatic “belly” breathing, and uses brief mindfulness and gratitude meditations, as well as techniques such as asking our kind self how to manage our own stress. Mind and body are a “bi-directional feedback loop…we can intervene at either level.” Dwelling on the negative keeps us physiologically aroused, which we in turn may appraise as a further concern. Changing our thoughts and our perspective can calm our bodily responses, and learning to physically relax increases our well-being. Most of all, forgiveness is about “purging your heart of bitterness,” he said. Amen.

academic lineage

Posted in psychology by Jim on April 14, 2010

William James was was the founding father of psychology in the U.S. He was born in New York City in 1842 and earned an MD at Harvard in 1869. He was fluent in five languages and personally knew John Stuart Mill, Tennyson, Thoreau, and Ralph Waldo Emerson. He studied theology, painting, philosophy, physiology and medicine. Although often sick or depressed, he taught physiology, then psychology, and then philosophy at Harvard. He was a beloved teacher, a good speaker and a prolific writer. He wrote and re-wrote The Principles of Psychology, which became the textbook of the field. He characterized his approach to psychology as introspective and pragmatic.  He died in 1910. (See http://en.wikipedia.org/wiki/William_james.)

One of James’s dissertation students at Harvard, Edwin Holt (1873-1946), helped to provide the transition from introspective philosophical psychology to behaviorism. As a professor at Harvard and Princeton, Holt tried to establish a very empirical, monistic view of perception, experience, and knowledge.

Along with Hugo Münsterberg, a student of Wilhelm Wundt (whom most would label the founder of the science of psychology), Holt chaired the dissertation of Edward Tolman (1886-1959), who became well-known in experimental psychology, especially for the concept of latent learning. He showed that rats learn mazes simply by exploring, demonstrating it in their later better performance under reward conditions. Tolman taught at UC Berkeley for 37 years. (See http://www.britannica.com/EBchecked/topic/269696/Edwin-B-Holt.)

One of Tolman’s dissertation students was Donald Thistlethwaite, who published in the areas of attitude change, latent learning, motivation, and educational environments. Thistlethwaite died in 1997, and his obituary appeared in the American Psychologist (in February, 1999): “He skillfully demonstrated distortions of logical reasoning caused by prejudice. Logical consistency in attitudes and beliefs remained a research focus throughout Don’s career…. Don’s comprehensive review of latent learning in the Psychological Bulletin in 1951, based on his dissertation, became the standard reference establishing that learning can occur without reinforcement.”

Attitude change studies were continued by Thistlethwaite’s dissertation student Ronald Rogers, who developed a “protection motivation theory” of behavior change in the health domain. In protection motivation theory, perceptions of health threats combine with appraisals of the ease and effectiveness of available coping responses, to form motivation to protect oneself. Rogers was my dissertation chair; I studied protection motivation theory across stages of cognitive development.