Exposure Therapy for Worries, Intrusive Thoughts, Ruminations, and Obsessions

Worries, ruminations, intrusive thoughts, and obsessional thoughts can be a terrible source of suffering.  If they are mild or infrequent, they can be part of a healthy, balanced life.  But when they are occurring frequently, they interfere with all of our activities.  They make it hard to enjoy anything.  A beautiful walk in the forest is interrupted by upsetting thoughts about daily stresses, or about painful events that happened long ago.  Attempts to work or study are interrupted constantly, preventing you from getting things done, and certainly preventing you from enjoying what you are doing.  If the intrusive thoughts have to do with past traumatic events, it is as if these terrible events are happening to you all over again.

In this post, I am exploring a challenging approach to this.  But I know that in many cases upsetting thoughts cause extreme pain and suffering, and therefore any therapeutic approach must be considered with very great care.  The approach I am proposing may not be right for you, unless you feel very well-prepared for work that could be difficult.   With any therapeutic approach, you must feel entirely in control of the therapeutic process.  You must never be pushed into any sort of therapy, even by a well-meaning therapist whom you trust entirely.  Sometimes the framework of therapy implies that you should be doing certain types of work.  Just coming to a therapy appointment can implicitly push you into engaging with certain therapeutic tasks, such as sharing a painful story about your past.  

But I believe it is of the greatest importance to be guided entirely by your own will, with any therapeutic task.   

Upsetting thoughts are problems in which an event is happening outside of your own will.  Past traumatic events also have happened against your will.  So it would be wrong to engage in a therapeutic effort, unless you are very clearly in agreement with it, and you are engaging in each step with the full force of your will and consent.

I am also aware that many therapeutic ideas can seem too focused on some particular "technique."  Sometimes we can focus too much on "technique" in such a way that we are distracted from the larger picture.  In the big picture, I believe that healing forces include gentle self-care, empathy, healthy lifestyle, and loving relationships.  So, regardless of whatever "techniques" you try, be careful to remember that the "big picture" factors are the most important of all.

But let's get started on looking at some "techniques," with these limitations in mind:

What strategies or techniques can help to manage anxious thoughts, worries, or ruminations?


The Problem with Relaxation Techniques

Most people, including therapists, focus on techniques to help calm the mind.  These could include relaxation or meditation techniques.  Most of us would also encourage healthy distraction techniques, such as trying to read a book, listen to music, "breathe," go for a walk, talk to a friend, have a bath, etc.  Many medication treatments also focus on relaxation.  Benzodiazepines, including lorazepam (Ativan), clonazepam (Clonopin), alprazolam (Xanax), or diazepam (Valium), often literally calm the mind, slow down racing thoughts, and reduce the distress caused by rumination or worry.

But the problem with these approaches is that they are primarily avoidance-based, rather than strength-based.

Analogously, if you are very fearful about swimming, it will absolutely relieve your anxiety if you distract yourself, meditate, read a book, or take a sedative, whenever you are close to a swimming pool--but, of course, these techniques will not help you to cure your anxiety!  The only cure must involve deliberately approaching the water, and gradually facing your fear!

In many cases, relaxation therapy (especially if it is the only approach used) can make underlying anxiety worse, because it consolidates the notion that the anxiety is intolerable and must be avoided.

Exposure-Based Techniques

Over the years, I have become more and more a fan of behavioural therapy ideas, for approaching a wide variety of psychological symptoms.  I believe that this approach is strength-based, and is similar to having a physical fitness regime, or a structured program of learning a new skill (such as speaking a new language, playing a new sport, enjoying a new hobby, or playing a new musical instrument).

To treat a phobia about swimming, it is easy to prescribe a behavioural therapy program.  The first step might be to just watch people swim, while you sit in the bleachers.  The next step could be sitting at the side of the pool, with your feet in the water.  Eventually you might walk in the shallow end of the pool.  This could build up to putting your head under the water, learning to float, etc.  Eventually, with practice, you could be swimming laps in the deep end (maybe with the help of a swim teacher).

But how could we devise a plan to treat anxious thoughts or ruminations, using this type of approach?

An idea I have been working with is to encourage patients to make a detailed record of anxious thoughts or ruminations.  Try to "catch" the thoughts verbatim -- as though you are taking dictation, or using quotation marks.  Then make an audio or video recording, of yourself reading these thoughts aloud, in a way which mimics as closely as possible the way in which the thoughts occur in your mind.    The recording then becomes something to practice listening to...the task is to sit calmly with your thoughts.  If anxiety comes as you listen, let it come.  Consider it a type of "workout" to face a difficult task.

As with other types of workouts, it is important to plan the duration and intensity so that it is challenging but not overwhelming.  It can't be too easy -- otherwise there would be no training or strengthening effect.  But it can't be too hard -- otherwise you could injure yourself, or just have an unpleasant experience that would discourage you from working out again.

With exposure to recordings of anxiety thoughts, you can adjust the intensity in a number of ways (this is analogous to adjusting the weights in the gym).  Here are three ways to adjust the intensity or difficulty:
1) just turn the volume of the recording down.
2) listen to the recording for very short periods of time, and gradually increase the duration as tolerated.
3) listen to recordings of thoughts which are less upsetting.  As you feel able, you can introduce more difficult or challenging thoughts.  
   

There are various phenomena that can happen which reduce the effectiveness of this technique.  The mind has strong reflexes to manage anxiety using avoidance.  When dealing with worries or intrusive thoughts, it is very common to want to respond to these thoughts by trying to reason with them, reassure yourself, problem-solve, or distract yourself in various ways.  With this technique, it is important to simply let the thoughts come, let the ensuing anxiety happen, without trying trying to reassure, problem-solve, or distract.

I am not saying that problem-solving is unhealthy!  Of course, problem-solving and reassurance are very important!  But not if they occur during this type of exercise!  Analogously, if you are lifting weights in the gym, you could roll the weight upwards using a ramp, instead of lifting it directly!  This would be using clever problem-solving to bring the weight to a higher point!  But you would not get stronger if you used the ramp!  Or you could use a flotation device in the pool...this would be a good solution to help you float safely.  But it would not help you to swim better, or to master your anxiety of deep water!

Another type of technique used commonly for managing worrying and rumination is "thought stopping."  There has been some research supporting it.  This would appear to be an avoidant technique.  But according to one analysis, the reason that thought stopping can sometimes appear to work is because the exercise often first calls for people to deliberately induce anxious thoughts!  Only after a period of exposure to the anxious thoughts do people then use a thought-stopping technique.  At this point, often the thoughts which are "stopped" are not the anxious thoughts themselves, but rather the compulsive self-reassurances or problem-solving attempts.  Therefore the thought-stopping is actually favouring a better anxiety exposure exercise!

Summary of the Technique

1) make a detailed list of anxious thoughts, to replicate as closely as possible how they occur in your mind
2) make a recording, in which you read these thoughts out loud
3) listen to the recording, as a type of psychological "workout"
4) adjust the volume, duration, and content of the recordings, so that it is moderately difficult for you, but not overwhelming.  Aim for an experience of "mastery" just as you would when you are lifting weights successfully at the gym, or when you are doing some other type of exercise
5) While you are listening, you could attempt to do other tasks that you normally would like to do, such as studying.  But work hard not to engage in "avoidance" behaviours such as distraction, reassurance, or even relaxation techniques
6) You could aim for about 20 minutes at a time...but you might need to start with much shorter durations, such as a few seconds, if you are very sensitive.  Once again, it is like starting to do a new exercise such as running...you may need to begin with running just a few steps, and then building up to longer distances as you get stronger.
7) After each exercise, you could then do some relaxation or other pleasant activities...just like soaking in the hot tub after a workout at the pool or gym...
8) Pay attention to how you feel in the next few days.  Just like workouts at the gym, you might feel "sore" in some ways.  Sometimes you might have more upsetting thoughts or nightmares, and feel worse.  If this is the case, you may need to make the next "workout" easier.
9) You may need to have a guide (such as a trusted therapist) to help you with this.  The role of the therapist, with respect to this technique, would be like a "personal trainer" at the gym--the therapist would be there to support you, encourage you, and help you with any problems along the way.
10) Sometimes a particular technique, such as this one,  may not be right for you.  If this is the case for you, remind yourself that it is not a sign of "failure."  It is just a sign that a different strategy is needed for now.  You might come back to a technique like this at a later time, or you may find other techniques that suit you better.


Is there still a role for Relaxation Techniques? 

To carry the fitness analogy further, I think most of us like to relax during part of our physical workouts.  Before or after our exercise, we might like to stretch, warm up, cool down, or relax in a hot-tub or sauna.  This could add to the enjoyment of the workout, and possibly even reduce the chance of injuries.

With an exposure-based anxiety management technique, perhaps some relaxation-oriented ideas could be used before or afterwards, in the same way.  It could help make your work a little bit more enjoyable, part of a pleasant routine.  It would just be important that your relaxation technique does not cause you to indulge in some kind of compulsive pattern that could contradict the work you were doing.

How other techniques already use this idea

In mindfulness-style meditation, the strategy is not to "empty your mind" or to prevent anxious thoughts.  The goal in mindfulness is acceptance and practicing attention without excessive reaction to sensations, feelings, or thoughts.   Worries or intrusive thoughts are viewed as clouds drifting through the sky of your consciousness, rather than attackers which need to be confronted.  Therefore, a person practicing mindfulness is also practicing being with the upsetting thoughts, rather than avoiding them.

In EMDR, various upsetting thoughts or memories can be contemplated while doing a physical activity.  In this way, arguably, the eye movements have a catalytic role to allow exposure practice to occur in a framework which feels therapeutic and well-boundaried.  A weakness in this technique, and possibly a reason that EMDR may work better with some therapists or clients than others, is that the eye movement activity could in some cases be an excessive distraction, and therefore dilute the effectiveness of the other therapeutic work.  But I think that provided this potential problem could be addressed, EMDR techniques could help a client and therapist adjust the intensity of a therapeutic session, analogous to adjusting the difficulty of a physical workout.

In conventional CBT, the initial phase of paying attention to upsetting thoughts, and recording them, is already a type of "exposure."  The act of writing something down can often require a strong act of will, and carry powerful symbolic value.  But a problem with cognitive therapy can sometimes be that the thought records become distractions, foster rumination, or lead to excessive debate or intellectual argument about thoughts.  

In psychodynamic styles of therapy, the experience of freely discussing painful thoughts and memories also involves exposure to the strong emotions associated with them.  Sometimes, in this style, the therapist's quiet presence is not directly "reassuring."  Rather, the therapist has a quiet role of facilitating exploration without a need for direct reassurance or problem-solving.  But a problem with psychodynamic styles has to do with its passivity--there is a lot of focus on exploration and "interpretation" but often not enough focus on strength and practical, immediate, active mastery of symptoms.   The preoccupation, in psychodynamic therapies, of searching for remote causation of symptoms, can distract clients or patients from working on strategies to master their anxiety in the present moment.  

Limitations

For many people, intrusive thoughts are occurring so frequently and intensely that it is hard to recommend deliberate exposure to even more upsetting thoughts.  It would be like recommending a demanding physical workout to someone who is exhausted or injured from a grueling daily routine of hard labour.    In these situations, it may be important to look at other techniques, including more of a focus on relaxation, or on medication, to help reach a state of calm restfulness, before beginning an exposure-based strategy.

If there is a history of psychosis or mania, then there would have to be a lot of caution about using this type of technique.  But I would not rule it out entirely...there is more and more evidence about CBT-style ideas being useful in managing psychosis.

If negative thoughts are part of a volatile pattern leading to dangerous behaviours, including suicide attempts, self-injury, destructive bouts of anger, or severe dissociation, then very great care would have to be taken to make sure that this type of technique was used in an especially slow, cautious manner if at all.  There might have to be some preparatory steps to make sure that the situation was safe and stable enough to proceed.  This is again similar to recommending a physical exercise routine to someone:  it is important to make sure that a person does not have joint problems, heart disease, etc. which could make the exercise dangerous.

In some types of depression, a person can feel self-destructive.  With this technique, excessive exposure to the content of upsetting thoughts could be self-injurious.  Self-destructive behaviour would need to be addressed first, in order to allow a technique such as this one to be safe and helpful.  
One of the most important things, with any type of therapy, but especially with a process such as this, is to frequently emphasize that it is completely up to the client or patient to engage with the technique or not.  The therapist must never push this.  The client must feel completely free to stop the technique at any time, without any concern that the therapist would somehow be disappointed or disapproving.


The Role of Medication

A goal of medications is usually to reduce anxiety directly.  But I think it is important to think of effective medication as a "catalyst" rather than a direct "cure."   Medication may reduce the severity of the underlying problem, so that other types of therapeutic work could take place more effectively. The effect of medication could be analogous to reducing the weights in the gym, or to using a flotation device to help you practice kicking in the swimming pool.    Without medication, sometimes the symptoms could be so severe that it is much more difficult or painful to do the therapeutic work.  It would be like going to a gym where the only barbells available had 200 pounds or more on them!

Some medication can also theoretically improve sleep or restfulness, and therefore allow you to do better and more enjoyable therapeutic work the next day, when you will feel more rested.  In other cases, medication could help with energy, allowing you to become more actively involved in all therapeutic tasks.  

Another dynamic in PTSD can be that uncomfortable experience is too quickly assimilated--perhaps via the amygdala--into a strong, aversive "emotional memory."  Past trauma, in combination with inherited factors, can make this type of neural pathway hypersensitive.  Arguably, some medications, including beta-blockers and other adrenergic antagonists,  could reduce the intensity of this reflex.   This would be analogous to a person with arthritis using an anti-inflammatory medication before doing physical exercise--the medication would allow the exercise to occur more comfortably, and with a lower chance of injury.     But I have to admit that it can be hard to find medications that are consistently helpful for this type of problem...I do think it is good to have an open mind about trying different approaches.


Conclusion

Upsetting thoughts can be a difficult problem, but I encourage patient, gentle persistence in a search for relief.  Remember the big picture, of patient, gentle self-care, healthy lifestyle, and nurturing loving relationships.

I do invite you to consider the possibility of finding ways to approach upsetting thoughts in a way which seems paradoxical--by finding a way to face them directly, and to practice having the thoughts rather than practicing ways to get rid of them.  This practice is not meant to be masochistic, but rather is meant to build a strength inside of you, so that the bully-like emotional effect of upsetting thoughts is gradually weakened as your strength improves.

References

There are not enough research studies done regarding approaches to rumination, primary obsessions, and other intrusive thoughts...but a similar exposure-based idea is described by  Salkovskis & Westbrook (1989).  I will look for other articles to expand my list of references later.

Salkovskis, P. M., & Westbrook, D. (1989). Behaviour therapy and obsessional ruminations: can failure be turned into success?. Behaviour research and therapy, 27(2), 149-160.

Garden metaphor

This is an update of a post I originally wrote in 2008.

The brain, or the mind, or your life, is like a garden.

It has grown for many years, and there are aspects to the structure that are, or become, permanent (e.g. the size and shape of the garden).

Some structures in the garden may be dominant (e.g. a tree that monopolizes sunlight, water, space, or nutrients).

Some structures may be permanent (a tree), others transient (some small flowering plants).

There may be weeds in the garden. Or maybe they are only "weeds" because someone has said they are weeds, just because they are considered weeds by other gardeners. Maybe the beauty and importance of many so-called weeds are overlooked.

There may be parts of the garden that are profoundly important, extremely beautiful, and extremely complex, yet are not noticed because we haven't looked in the right way (e.g. tiny flowers; micro-organisms; ladybugs; close-up views of the structure of the leaves, etc.).

Old or dying plants may be integral parts of the normal life cycle of the garden, as things of beauty in themselves, and as components that help new life to grow.

There may be diseases in the garden that do harm in different ways (above the soil or below).

There may have been terrible events long ago that have done severe harm (a fire; an oil spill; a vandal; a careless former gardener; bad droughts or storms; a lighting strike).

The garden requires a healthy environment to grow, both above and below the soil. Sunlight, water, nutrients, soil conditioning.

The structure of the garden can get tangled up and confused if it isn't tended to regularly. It can get messy. The tangles may prevent certain beautiful plants from being cared for or thriving. The tangles can occur above the ground, or down underneath at the root level.

The structure of the garden can be stunted if it is tended excessively -- the overzealous pruner who cuts too many branches away, instead of letting the natural shapes and stems grow spontaneously.

In healing a troubled garden, sometimes simple, broad measures can make a huge difference (e.g. adding nutrients to the soil; introducing a new type of soil; keeping up this supplementation for months or years).

Other times, or perhaps in conjunction, work may need to be done to prune or guide the garden differently, above and below the ground. Some of this work can happen in a day, other aspects of this work could take years.

Maybe a major change is needed. A huge plant that is taking up all the space, water, and light, may need to be removed, so that other plants have a chance to grow.

Sometimes things that supposedly help need to be cut back -- maybe the garden is being over-watered, or is getting too much sun. Many of the plants may require moderation in order to thrive. There can be too much of a good thing.

New species may need to be introduced, to balance the health and esthetics of the garden. Synergistic benefits can happen with the right combination of species (two different species may help each other grow if they are adjacent to one another).

The effects of past trauma in the garden may gradually heal with care and attention. Some of the scars of the trauma may remain forever. Even if these scars remain, the other plants of the garden, and the gardener, can support the injured plant, help it be a vital, important, and beautiful part of the garden community.

While caring for the garden may be hard work, the process is intrinsically a joy. The results of the gardening are part of the health, but so is the process of the gardening activity itself.

In caring for your mind, you are taking on a role of gardener.  It is possible to "tend the soil" in many ways.  Part of this requires physical labour to improve the texture and drainage.  Sometimes the soil may be depleted or damaged in some way, and a fertilizer may be needed, at least for a little while.  This could be similar to using medication.  But also there are many other ways to care for the "soil," such as by having a healthy diet.  Psychotherapy is analogous to hiring a gardener to help and advise you, and maybe to work with you, kneeling in the soil, or pruning the branches.  Sometimes major structural changes may be needed, to plant the garden in a completely different way...this is akin to making a substantial change in the organization of your life, your goals, and your relationships.  And the best gardens are attuned to the larger ecosystem around it, including other gardens in the neighbourhood.  This is analogous to the need to healthily engage in your community, and in relationships with others.    Part of the life of a garden, and of a gardener, also requires simply sitting down and enjoying its beauty.

There may be hard work to do, but there must also be a lot of time spent simply savouring your efforts, and enjoying the view.  I hope that a good therapist might do this with you as well.  Make sure there is a bench in your garden, in a shady spot, in order to rest and enjoy.  In your life, there may be a lot of work to do, but make sure to spend time, every day, sitting down and enjoying what you have been working on.

The Virtue of Admitting Weaknesses

I think it is a virtue to admit areas of weakness.  In our modern, competitive world, we are encouraged never to admit our shortcomings.  On a résumé or CV, the standard practice is to provide a list of our accomplishments, awards, and strengths, but never to discuss weaknesses!   In current events today, we can find many examples of public figures who not only would never admit any sort of weakness, but who boast about themselves almost constantly!   Admissions of weakness could seem like manifestations of low self-esteem, low confidence, or proof of incompetence.  

I think it is a strength to be able to admit weaknesses!  It is a protection against poor decision-making, and a protection against cognitive biases, to always contemplate weaknesses or mistakes in your planning.  For example, Kahneman described a technique called a "pre-mortem" which calls for us to anticipate or imagine that our plans had failed badly, and then to imagine the sequence of events that could have led to the failure.   Too often, groups are so excited about new plans that they are blinded by "groupthink" and do not consider adverse consequences.  While this often happens in business planning, it frequently occurs in our personal lives as well.  

In medical training, it can be important to show confidence.  But imagine how dangerous it is for patient care when a trainee is reluctant to admit a weakness in performing a medical procedure!  In this case, it is a sign of strong professionalism and leadership to admit that you don’t know.  Ironically, it can require great confidence and self-esteem to be able to convey these weaknesses honestly.  

 In the spirit of admitting weaknesses, I would like to list a few things that I don't think I'm very good at, in my professional life: 

1) teaching meditation.  I know that meditation skills can be important and powerful.  I encourage almost all my patients to learn about meditation, and to consider investing a lot of time practicing meditation skills.  I think I am good at philosophizing about meditation...but not really good at meditation itself! Mind you, I do think that my philosophizing has a meditative quality--at least it does for me! 

I am willing and eager to learn more about meditation, but I also know that a good meditation teacher or group would be more effective and helpful for my patients to learn meditation skills.  I feel the same way about some other related activities such as yoga. 

2) being a very organized, methodical teacher (e.g. for CBT exercises).  I love intellectual dialogue, and I enjoy trying to give encouraging, creative feedback...but I know that sometimes a good teacher needs to be very organized, consistent, strict, and focused on a task...My style tends to more informal, with variations of focus from week to week, according to my patients’ wishes.     Also, I tend to question things a lot, including the process of things, so I think I would find a highly regimented style to be too restricted.  Some patients who desire a more strictly regimented approach might get frustrated with me.  At other times, maybe I don’t use time as efficiently as I could.  

I am willing to learn more about becoming a better and more organized teacher--but I also recognize that I have limitations with those skills, and that there are others who could do a better job than I could.  

3) "Networking" with community resources.  I have a tendency to have a bit of a "monastic" style.  While I encourage patients to inform themselves about community resources, and to make use of them, I tend to prefer spending most of the time working one-on-one with my patients, instead of spending time developing relationships or engaging professional peers in other parts of the community.  For similar reasons, I prefer to do a lot of my continuing education activities on my own, through reading and writing, rather than signing up for conferences.  

I realize that we all need a balance between "alone time" and "group time" in our lives.  This applies to professional life as well--different professionals may like or need different amounts of interaction with professional peers.   I think it is unhealthy for anyone to be too extreme in this balance, but on the other hand I do think it is important and good to honour your own personal style.  

The practice of psychiatry nowadays tends to favour more "community networking" and less of a "monastic" style.  I see that this can be valuable, because it could lead to more of an experience of a collaborative therapeutic community.    For me, I guess my lack of inclination to network this way is a weakness...but I hope some might find it a welcome strength that I value the one-on-one experience as highly as I do.

4) not empathizing enough.  Sometimes I focus too much on intellectual dialog, on problem-solving attempts, on being calmly attentive, etc. – but then I don’t say an empathic comment that needed to be said.  Here, I need to be more diligent to work on this, but also maybe to admit that this happens more often than I care to admit.  

I have a variety of other weaknesses.   I encourage a practice of being honest about our weaknesses, not in a resigned or self-deprecating way, but in a way which helps us acknowledge our humanity and our fallibility.  

Ironically, I am concerned that I might sound boastful -- I am boasting that I can talk about my weaknesses!  Maybe my own boastfulness is another weakness, to be worked on.

  
Also, in conjunction with admitting weakness, I think it is good to acknowledge that some of our strengths actually depend on the weaknesses!  Maybe my weakness regarding networking comes along with a strength for valuing one-on-one therapeutic relationships...perhaps some of your weaknesses which you struggle with are part of a larger picture of having strengths which could allow you greater meaning and purpose in life.

With the admission of weaknesses, I think it is also good to be open-minded about working on them.  Not necessarily with a goal to become a different person--it is important to "be yourself"--but with a goal of spending a little bit of time and attention on our weaknesses in a constructive way.  For me, this means that I need to spend a little bit more time learning about meditation.  I need to consciously say more empathic remarks.   I need to maybe sign up for a few more conferences.  And I need to push myself a little bit to attend more meetings with colleagues in the community.   But I can’t let these goals interfere with the aspects of my professional life that I already enjoy and feel comfortable with. 

Persuasive Factors in Politics

In my previous posts, I was describing some of Cialdini's factors which affect decision-making and persuasion.

It is interesting to look at some of these factors playing out in current news events:

Why do people adhere to a particular political choice?

Many people insist that they support a particular political candidate, simply because that candidate has the best policies, or has the best leadership skills.  Or they support an ideological position, or a whole system of values, because they believe, and feel, that they are the best.

But are there other factors at play?  Let's look at some of Cialdini's persuasion factors to consider how they affect candidate or political choice:

1) Consistency & Commitment.  If a person has already supported a candidate, a political party, or a position, then that person is more likely to maintain their choice, even if circumstances change.  We form loyal attachments to our previous choices, even if the attachment is shown to be irrational or harmful.   It may seem humiliating, embarrassing, or weak, to bail out on a previous choice.   It might feel similar to abandoning a marriage, a job, or a responsibility, just because things are going through a rough patch.

This consistency factor is especially strong if the person has grown up in a culture where consistency or commitments are considered strong points of honour.   This culture of honour is to be respected.  Loyalty is to be respected!  But unfortunately, this loyalty can cause people to keep supporting, for too long,  something that is harmful...it can cause people to overlook negatives in their position, and to go along with things that they would never have rationally supported were it not for their previous commitment.

A related cognitive bias is the "sunk cost fallacy":  if you have already invested a lot of time, energy, or money into something, you are more likely to continue pursuing it, even if it is irrational to do so, and even if the project is failing disastrously.   It may feel humiliating or shameful to change your mind, even if changing your mind could save you from bankruptcy!  It can take courage to let a previous commitment go!

Commitment and consistency are bolstered by community and family factors:  if most people among your cultural group, family, or coworkers have all been supporting a particular group, idea, or candidate, then it could seem intensely disloyal to disavow your own support or commitment.  You might even fear that your peers or family could reject you if you changed your mind.

So, commitment and consistency are powerful, noble forces in decision-making, and in life, but we must not be enslaved by these factors...it is a sign of a much greater character strength to sometimes over-ride this, and to make a deeply moral choice to let go of a previously held commitment.  

There are many tragic stories in history, where massive segments of the population of great societies follow disastrous ideas and leaders, partly due to the persuasive force of consistency.

2) Social pressure.  If many people continue to support a particular thing, then it is easier to keep supporting it yourself, even when this is irrational.  We all have a tendency to follow a trend...sometimes we follow these trends, along with an excited, passionate crowd, even when the crowd is rushing towards the edge of a cliff!  Beware of  "GroupThink!"

3) Liking & Authority.  We form positive emotional connections with candidates or positions we support, and we may also respect their authority...trust and admiration grows with any ongoing relationship, and we may continue to make decisions influenced by this.  If we "like" a political candidate, we may support that person long after it makes rational sense to do so.  Conversely, it may be difficult to support a candidate we do not personally "like," even if this candidate may offer the best leadership.   Some of these factors can be incredibly irrational, such as supporting a person whom we find better-looking or more entertaining!

When these factors have been at play, and we support something, we are likely to invest our time, attention, energy, and money...we may even suffer and struggle for these causes.  Our struggles and suffering usually intensify our attachment, and make us even more resistant to letting it go when it is morally right to do so.   If you have fought for something, you are much more likely to keep fighting for it, even if your cause is proven to be unjust.

It is our duty as citizens, or as participants in any community,  to make wise choices, and to be willing to change our minds after thinking carefully.  You need a great strength of character to take an honest, balanced look at both sides of every major issue or position.   You are not just born with character strength--you must work at it, and develop it as an essential life skill!  In politics, it is important to give sincere attention to multiple sources of information, and not to rely only on a single news source which happens to support your pre-existing point of view.

I am very alarmed about situations--which we see across the world today--in which there is restricted freedom of speech and expression.   Many news sources are overtly supporting only one position.  In some countries, the government is restricting free debate in the media.  Even closer to home, individual news sources are focusing on telling only one side of many stories...  We must protect our freedom of expression!  It is not only a matter of taking care of our freedoms, it is also a matter of making wise, unbiased decisions!  Wise decision-making is impossible unless we fairly attend to multiple points of view, and unless we are willing to challenge our own individual biases.

Cialdini tells an interesting story about the decline of tobacco use in the U.S., associated with a policy called the "Fairness Doctrine" which required equal time to be given to opposing viewpoints.  If tobacco ads were always followed by other ads trying to show the harms of smoking, it led the viewer to make a more balanced decision (which, in this case, led to a decline in smoking).  Ironically, once tobacco advertising disappeared entirely, smoking rates did not decline as much.  Part of an explanation is that tobacco advertising could then occur in more covert forms, perhaps marketed more exclusively to existing smokers, without equal time given to opposing viewpoints.  The best decision-making occurs not when issues are suppressed, but when powerful counter-arguments can be presented in a free society, by a free press, where opposing positions can always be clearly shown, side by side.  

It takes a great strength of character to be willing to change our minds,  and to make an intelligent, morally-guided choice, in the face of powerful persuasive factors such as consistency, social pressure, liking, and authority.  We can all improve this character strength, if we are willing to challenge ourselves, and if we are willing to work hard!

The Psychology of Language Use: Big Words & Zombie Nouns

I'm very interested in the use of language, as a joy of life, and as a factor in psychological health.

Poetry and rhetoric are beautiful and powerful forms of self-expression,  and of beginning a dialog with others in an effort to solve problems.

It is therapeutic to have a forum to express yourself.    Journaling can be a part of psychological well-being, as a way to process past adversity or trauma, and  as a way to manage anxiety.  One of the most meaningful aspects of psychotherapy can be to share your story out loud with a supportive, respectful therapist.

One of the problems with some new  brief styles of mental health care can be that there is very little comfortable space given for  expressing yourself in this way.    Instead, care is guided by questionnaires, symptom reviews, and mechanical treatment algorithms.

This blog has been enjoyable for me to write.  I had always wanted to do some writing.  It has been good for my own health, in many ways.  It has been my own self-expression!

I do enjoy writing...but I'm quite conscious that my style of writing may not actually be that enjoyable for many readers.   The way I speak, and write, often can sound really formal and wordy...I would like to work on this, but it can be hard to change these habits.  Also, I want to use my actual, authentic voice, which actually is a bit formal and wordy!

During the past year, I have come across many examples of language use which have bothered me...in fact, this is one of the big reasons I am writing this post today.

To explain, there are two authors I'd like to refer to...

Daniel Oppenheimer: Using Long Words Needlessly

The first is Princeton Professor Daniel Oppenheimer, who in 2006 published an amusing article called "Consequences of Erudite Vernacular Utilized Irrespective of Necessity: Problems with Using Long Words Needlessly."

He showed, quite simply, from 5 experiments, that if you use bigger, longer words, people will form an impression that you are less intelligent!   In his words, "needless complexity leads to negative evaluations."   The use of jargon and complex vocabulary can sometimes be an indication of being part of an "in-group."  But especially in mental health discussions, it is vitally important that the therapeutic community not be an "in group" separate from the community of clients!   This is one extremely important reason to avoid such jargon!

Here is another useful quote from his discussion:

Pennebaker and Lay (2002) have shown that people are more likely to use big words when they are feeling the most insecure...leaders facing crucial decisions might use more complex vocabulary and end up undermining others’ confidence in their leadership ability. Thus it may be worthwhile to investigate ways of either preventing the tendency to use needless complexity, or look at ways that fluency biases might be overcome.
In the interim, we can conclude one thing...write clearly and
simply if you can, and you’ll be more likely to be thought of as intelligent.

In discussions about health care and wellness, as in other communications from daily life, it is good to strive towards beauty and clarity in language.  Beauty and clarity are intrinsically healthy and comforting.  Awkward language, jargon, and rambling, confused text induce anxiety, stress, and irritation in the reader or listener.


Steven Pinker:  Zombie Nouns 

The second author is the famous linguist and psychologist Steven Pinker, who recently published a  book called The Sense of Style: The Thinking Person's Guide to Writing in the 21st Century (Penguin, 2014).

Pinker has a refreshing approach to looking at writing style and grammar use, with an interesting focus on the history and background of stylistic rules.  Many grammar and style rules are cultural variants, and are often held more strictly than is appropriate, especially given their often arbitrary nature.  Many of our greatest authors have often violated various style or grammar "rules."

Pinker describes a particular style problem, which is prevalent among academics and bureaucrats.  This type of talk is common in politics and in corporate lingo and jargon.  He calls this "bureaucratese, corporatese, legalese, medicalese, or officialese."  

...as I browse through Pinker's book again, I find myself  self-conscious about my own writing style, right now...here's a quote attributed to Mark Twain, which shows that I'm not following good style advice right now myself:

substitute damn every time you're inclined to write very [or quite, or especially, or particularly, etc.]; your editor will delete it and the writing will be just as it should be.

Anyway, I think Pinker is so right about the need to work on better style, to make language more beautiful, expressive, and enjoyable...

A lot of Pinker's illustrations are quite funny.  I had a good laugh when he referred to the word "model" as "a verbal coffin,"   There is a lot of "model" talk in health care planning--too much talk about "models" and too little time taking care of patients or clients in need!    

 Another term Pinker uses is "zombie nouns."  This is the confusing, pedantic use of words which are almost neologisms, where a noun is turned into a new verb, or perhaps back into a noun again with extra suffixes.   This language use imposes a sort of "in group" status upon those engaging in it...which could be useful for a team working on a narrow project, but not healthy for a team hoping to serve and interact with the community in a sensitive and empathic way.

Here are some variations of this:

noun into verb into noun again:  "languaging"
adjective into noun: "the collaborative,"  "competencies"
noun into verb: "effectualizing"
noun into adjective into verb: "operationalize"


Applications for Healthy Living

I encourage you to practice using your voice!  I mean this literally, in terms of speaking out loud!  I also mean it figuratively, in terms of writing and expressing yourself in other media.

If you do some writing, such as in a journal, pay attention both to the content (which could be writing about painful life experiences, about things you feel gratitude for, or about musings of your imagination), but also to the process.   Enjoy language, and form a style which is sincere, expressive, and beautiful!  If you are writing or speaking for other people, then be sure to empathize with your audience, and to consider ways to make your communication understandable and engaging.


Oppenheimer, DM (2006).  Consequences of erudite vernacular utilized irrespective of necessity:  Problems with using long words needlessly.  Applied Cognitive Psychology, 20(20), 139-156.

Pinker, S. (2015).  The sense of style:  The thinking person's guide to writing in the 21st century. Penguin Books.

"GroupThink"

One of my favourite areas of psychology has to do with the study of persuasion, and of the cognitive biases involved with this.

There are two very important researchers who have written extensively about this:  Robert Cialdini (an expert in the psychology of persuasion), and Daniel Kahneman (an expert in the psychology of cognitive biases).   

Cialdini: Persuasion

I highly recommend that everyone be familiar with Cialdini's work, because it relates to making good decisions in the modern world.  Cialdini has spent decades studying the persuasive techniques which are used in sales and marketing, with the rigorous and thoughtful eye of a scientist and experimental social psychologist.  A problem with Cialdini, however, is that his books seem too focused on an audience of business people and marketers. 

Kahneman: Cognitive Biases

Kahneman's work focuses more on the cognitive mechanisms that affect judgment, and this area is an important complement to Cialdini.   Kahneman is the only psychologist to have won the Nobel prize!  His psychological work is very relevant to economics--it is a quantitative look at how human cognitive biases affect all decision making, including small and large economic or financial decisions.  

Why is this Important?

Cialdini -- and probably Kahneman too -- are most appreciated by people in the business community, especially marketers, since their ideas are likely to help any business earn more profit.  But I think these ideas should be part of everyone's knowledge base, since they will help us all to protect ourselves from being influenced by marketing in an unwelcome way.   Not just obvious marketing, such as commercial advertising, but also subtler forms of "marketing," such as experiencing persuasive forces in the workplace, in the media, in politics, and even in our personal or social lives.  

Persuasive Factors

In his initial work, Cialdini described 6 factors contributing to persuasion:

1) Reciprocity.  If someone gives you something, you will be more apt to give something back, including your approval or support!   If you are treated to lunch, you will be more likely to comply with someone's request afterwards!  This is a normal, natural thing, and even part of good social skills...but be careful about this, because sometimes the person giving you a free lunch may have an agenda to change your mind about something that you would otherwise not want to change.  A very troubling example of this in current events is of extremist groups providing free food, shelter, and other care to people in need...while helping people in need is wonderful, it also leads the people receiving this help to be more likely to join the extremist group!   We can address this problem politically by making a big effort to help people in need long before an extremist group does, rather than focusing only on military solutions to such problems!  

2) Consistency. Once you have done a certain action, or agreed to a certain thing, or committed in a small way to a certain thing, you are more likely to go further with that same thing in the future.  If you once joined a particular political party, you will be much more likely to keep supporting it in the future, even if you would otherwise disagree.  If your parents and grandparents have always supported a certain political or religious group, you will be more likely to also support the same group, since it could seem inconsistent, or even a "betrayal," to change your mind or your actions.  This consistency can be a great thing--it is part of maintaining a personal or community culture.  But it can also cause people to be "stuck" with ideas or behaviours which are unhealthy or harmful, yet with a resistance to change.   Marketers use this phenomenon all the time, by encouraging you to become a "member" of a points plan for a particular business, to have consumer "loyalty" programs, by having you formally endorse one of their products, which leads to a long-term tendency to choose the same products again.   

Be careful about this one!  Consistency is good, but not if it prevents us from changing our mind when change is needed.  Some of the most disastrous events in world history happened when people's consistency and commitment led them down a dark path...

3) Social Pressure, or Social Proof.  If you see that something is becoming more popular, you are more apt to support it.  Suppose you are starving in the woods, and you see bushes with berries on them.  You are not sure whether they are poisonous or safe.  If you see other people happily eating those same berries, you will obviously be reassured that they are safe, and you will happily pick some berries for yourself!  In this case, social proof is very useful and protective.  But marketers routinely use information about social proof to push us to support things or buy things.  Even the polls that we see in the media can have this effect:  if someone claims that a particular candidate is soaring in popularity, many people will be more likely to join in and support that person as well.  This effect is especially pronounced if the social proof comes from people who are similar to us in some way.  For example, if you are shown that most people who are around your age, and who come from a similar ethnic background, and who share similar cultural interests, are all supporting a particular political candidate, you will be more likely to be persuaded to support this candidate as well.  

Once again, this is a normal and often efficient way to make decisions in life, by assessing the decisions that similar people are making already.  It is what Kahneman calls a "cognitive short-cut."  

But marketers use this factor all the time, to push us to support things, or to buy things, that we otherwise would not want.   

4) Liking.  If someone you really like asks you to do something, or to change your mind, you are more likely to comply!  This is again a completely normal, understandable, and often useful human behaviour.  But be careful with this one!  Marketers, politicians, and even people in your social circle could sometimes push you to make decisions you otherwise would not make, just by being nice, and by being "likeable."  The stereotype of a "con man" usually includes being physically attractive, charming, and superficially likeable.  Be careful not to let these factors affect your judgment more than you want!  

5) Authority.  This is a huge factor, both in the marketplace and in a professional work environment.  It is another very useful cognitive short-cut to assume that an "expert" has good advice.  Often the expert or authority (such as a famous doctor or researcher) really does have useful advice and wisdom!  But people are easily prone to shutting off their critical judgment if they are told something by an expert.  In many cases, an expert may have a particular agenda for change which is not directly related to their expertise.  And in many cases, a speaker may be granted more "authority" or expert status than is reasonably warranted.  For example, it is a tradition for speakers at a meeting or conference to be introduced with a glowing biographical vignette, summarizing a list of very impressive credentials, degrees, awards, and a publication record.  These facts may be completely accurate, but it is important to know that this introduction will increase the speaker's persuasive influence over the audience...While this is often useful and reasonable, it could also often give the speaker license to influence the audience about all sorts of things that are outside of their expertise!  

I have seen this in my work very often:  a speaker with impressive credentials is greatly respected by the audience.  The speaker's ideas about treatment strategies (e.g. medication or therapy approaches for treating depression) or about health care policy (e.g. how to set up an efficient medical system) are accepted by the audience in a much more uncritical way, with much less reasoned debate, than would be the case if the same ideas were shared without the introductory eulogy about credentials!  

Be careful when you see a commercial featuring an esteemed expert or authority endorsing a product.  The information you hear should be considered seriously, but remind yourself that you may exaggerate the validity of this information, simply because you respect the expert's authority.  Always question authority!  Don't reject it outright, but always question it!  

6) Scarcity.  If you know that something is rare, or disappearing, you are more likely to desire it more.  This factor is routinely used in sales and marketing:  if a particular product is "disappearing fast,"  or if you are told it is your "last chance" then you are more likely to be interested in it.  If you are guided to believe that you have some kind of rare, special, personalized knowledge about something, then you are more likely to act on it. 

In marketing and politics, the fear of loss can have an exaggerated influence on people's decision making.  The fear of loss of security or safety can lead to a greatly increased focus on policies addressing this (e.g. military or policing issues).  While it is reasonable to focus on such things, ironically the fear involved can distract attention away from other policy factors which would ultimately have a much better chance of improving safety (such as enhancing diplomacy, improving education, focusing resources on eliminating poverty, etc.) 

In Cialdini's more recent work, we could add another factor, one which Kahneman has talked about extensively as well.  It is something which all the other 6 factors incorporate to some degree as well:  

7) Guided Attention & the Focusing Illusion

If our attention is guided towards something, we are much more likely to assume that this thing is important, and that it has some causal influence.  A magician or illusionist routinely makes use of this...most magic tricks involve carefully guided attention, so that we don't notice the magician fooling us, right in front of our eyes!   I encourage you to look at some YouTube videos showing clever illusionists using this phenomenon; here's a good example: https://www.youtube.com/watch?v=GZGY0wPAnus

This factor is arguably the most powerful of all persuasive influences.   When a person or a group is focusing on something, we will be guided into thinking that this focus is more important and causal than it really is, and it will prevent the person or group from asking other important questions!  

Cialdini gives a good example of this, having to do with the journalists who were allowed to cover a recent war.  The journalists were given unique, unprecedented "embedded" access to soldiers in their daily lives.  On the one hand, this allowed a valuable transparency about the goings on in the war.  It led to a focus upon the daily dramas in the life of a soldier:  the harsh climate, the food, the camaraderie and bonding with fellow soldiers, and especially the heroism, bravery, and self-sacrifice involved in the battles.   As a result of this focus, the viewers would form an understandable and healthy attachment to the human stories on the battleground, and would form a completely normal and healthy admiration for the bravery and nobility of the soldiers.  But--because of this, the viewer would be less likely to question the strategy of the war itself!   

The manner in which a story is focused upon can distract us from asking other questions about the story, which may need to be asked!  

In a work environment, there could be a new policy scheme, which in some ways could be similar to the example above...it could involve honourable, devoted, intensive efforts from many warm-hearted people, all of whom nobly striving towards making things better.  But once such a plan is in action, the attention of the group becomes focused upon the daily "battles" and human dramas associated with enacting the plan.   The group is much less likely to question the strategy of the plan itself, even if the plan is unhealthy or harmful.  

One can see this in political movements:  supporters of a particular political party or candidate are working very hard, are forming strong social and emotional bonds with the cause...they are motivated honourably, often with strong wishes to make the country better.  There are daily struggles with polls, with debates, with interviews, with criticisms from opponents...these struggles are analogous to a battlefield.  The stories involved with the battles are dramatic and engaging, and the media on both sides of the battle are eager to focus on them.   But because of this, supporters are likely to simply focus on continuing the battle they started, rather than pausing, reflecting, thinking deeply, and being willing to change their strategy or beliefs if necessary and morally right.   

GroupThink

So, this is what I mean by "GroupThink."  It is going along with what other people are thinking...due to reciprocity, consistency, social pressure, liking, authority, and the focusing illusion...we then risk getting caught up in things that aren't good for us.  

"GroupThink" can often be efficient, to get certain tasks done.  If everyone in a group is constantly stopping, reflecting, and questioning themselves, then the group's actions could be frozen...but we must always at least be aware of how powerful "GroupThink" is, and how it affects all of us.  The antidote for this, the way to keep this force balanced, is to always be willing to question things!  

Be willing to question others, even authorities, even people whom you really like!  Be willing to question yourself!  Just because you have thought, felt, or done a certain thing for a long time doesn't mean you can't change your mind, your feelings, or your actions!   

Be aware that there are powerful persuasive factors in our lives, all around us...we don't have to be afraid of them, but we do need to know that it can be easy to follow these factors passively.  We can live healthier, happier, more satisfying lives if we take some time to step back, think carefully about our decisions, and be willing to speak up!  

Mental Health Care Triage

What is Triage?

"Triage" is a term used in medicine, referring to the process of deciding the order in which patients should be seen and attended to, if many are waiting.

If you are waiting for something, such as for a table at a restaurant,  the first person to arrive is served first.  An even higher priority is also given to people who have made "reservations," or who have arranged their appointments in advance.

In an emergency room, a different system is needed.  Even if you have been in the waiting room for several hours with a broken ankle, a person just arriving with a heart attack must be seen right away, before you!   It generally would not work to make "reservations" at the emergency room, except maybe if you are on your way in an ambulance.

Triage involves not only deciding what order in which patients should be seen, it also involves deciding what type of service should be provided to each person.

If everyone with abdominal pain was sent to a surgeon, it would be inefficient...most cases of abdominal pain do not need surgical treatment.  If these non-surgical cases were all seen by the surgeon, then the surgeon would be too busy to deal with the true surgical emergencies!

In mental health care, it can be efficient to have a triage process.  But how to do this?

Assessment

The most common strategy is to offer some form of "assessment" which then could guide a triage decision.  This usually would involve an interview.  It could involve filling out questionnaires.  Based on the results of the interview and the questionnaire results, a decision could be made about whether some form of counseling might be needed, or perhaps a visit to a physician, a referral to a psychiatrist, or even an urgent trip to the hospital.   In other cases, a bit of simple reassurance, simple lifestyle or self-care advice might be really helpful.

The benefits of an efficient triage process would be that others in the system could then see clients or patients whose particular problems or levels of severity were well-matched to the skills of the particular caregiver.  All caregivers in the system would spend less time dealing with situations that were outside their scope of experience or expertise.

Potential Problems 

What are some of the potential problems of a mental health triage process?


1) The first issue has to do with the reliance on a single interview, and on questionnaire data.  In a great many cases, this is an efficient, helpful process.  But in some cases, an ongoing relationship is needed to understand mental health issues.  People may not be willing to share sensitive issues with someone who will only be seeing them once.  People may not be willing to divulge sensitive information in a questionnaire, which will then be handed in to a stranger.   Some people may have a very clear reason to desire a therapeutic relationship of a particular type, without wanting to explain their reasons in detail to a stranger who would only be seeing them once.

So the triage system, involving interviews and questionnaires, must have the flexibility to accommodate situations of this type.  Basically, it should have strong consideration for patients' or clients' wishes for privacy, discretion, confidentiality, and therapeutic resources, while not being rigidly adherent to questionnaire or interview data.

A simple remedy for this problem can be for individual patients or clients to have the ability to make a direct request for a particular type of care, without having to "jump through the hoop" of a triage assessment visit.  Many people who desire a therapeutic relationship will not benefit from going over their history with a stranger who will not be seeing them in the future.  In fact, the triage step will just add to their stress, and could lead to a feeling of having to negotiate yet another bureaucracy.

2) The second issue has to do with the quality of life of people working in the system.  In my experience, emergency psychiatry is a very stressful area of mental health care.  Practitioners in this area can often become burned out or even cynical over time, if this is the only type of work that they are doing.  The reasons for this are not simply related to the severity of the problems seen in the emergency room:  it is also because emergency workers usually do not follow the patients or clients after their emergency visits.  Therefore, they do not get to see their patients or clients recover!  They may not have the satisfaction or enjoyment of working with someone over a period of time, and seeing their progress.    Furthermore, if they are only doing emergency or triage tasks, their clinical skills for doing other types of ongoing health care will weaken or atrophy.  

I believe that a big part of the joy of being a therapist or a physician, involves getting to know your clients and patients on an ongoing basis, sometimes for long periods of time.  It can be demoralizing and stressful to only be seeing people a single time, or only be seeing people who are severely ill.

There is a simple remedy for this problem:  in any triage system, or emergency care system, it can be valuable for different staff to take turns doing triage tasks.  Each staff person should also have the opportunity, at other times,  to follow some patients or clients for ongoing care.   This would help staff to maintain better morale, and to maintain better clinical skills beyond "assessment."

3) A third issue has to do with the risks of a supposedly "efficient" system becoming more and more like a mechanical or impersonal bureaucracy.   As questionnaire-based systems become more and more prevalent, we may start talking more and more about "PHQ-9" scores, and less and less about a person's story.   Furthermore, score-based assessments in mental health may lead to false conclusions about what is truly helpful.  For example, a person in great distress may enter an emergency room on a Friday night with an extremely high score.  That person might have an unpleasant experience on a stretcher in a noisy hallway on Friday night, then a frightening experience on a busy emergency ward for the next day.  On Sunday afternoon, the symptom questionnaire may be repeated, yielding a greatly reduced score.  The conclusion may be that the emergency room experience was profoundly helpful!   In this case, the symptom score diminished because of the passage of time, and perhaps because of a physical place that was safe in some ways.  Other types of harms may well have been done because of this experience (for example, the person may dread ever having to go to the hospital again), but this harm would not be detected on a cross-sectional symptom scoresheet.   The harm would be apparent, however, if we were to have a conversation with this person rather than just give them a questionnaire.

Symptom questionnaires are very imperfect guides, and should never be the foundation of any type of health care, especially in mental health  (see my previous post about questionnaires: http://garthkroeker.blogspot.ca/2015/11/the-business-of-psychological.html).  I do think they have their role, and people could be invited to use them, but there is a risk of both the patient or client, and the caregiver, paying too much attention to questionnaires, and too little attention to other aspects of care or need.

4) A fourth issue has to do with allocation of health care resources.  While triage could improve efficiency, and allow more people to get the help they need, it could also in some cases be an unnecessary bureaucratic hurdle.  The same money and resources spent on a triage system could instead be spent simply hiring more counselors, who could manage their own triage.  In many private counseling regimes, a person seeking a counseling relationship is already "self-triaging" and can inquire on their own with the therapist about the possible types of care available or needed.  

This issue is similar to the Electronic Health Records (EHR) issue:  an innovative device, triage system, or "model" may be useful in some ways, but it must always be in service of a higher value, which is to provide personal, empathic, attentive, ongoing care to those who desire it, and to allow a healthy, balanced, meaningful work environment for therapists.

Electronic Health Records (EHR)

Electronic health records allow for a variety of improvements in medical practice and health care:

Communication between physicians can be improved.

Lab results can be coordinated and exchanged efficiently, with a reduction in the chance of results being overlooked.

Patients or clients of a health care service can become more directly involved in perusing their own health records, and therefore could have a more empowered, active role in their health care.

Some systems can also allow prescriptions, other treatments, and symptoms to be tracked efficiently over time.

Patients could also contribute information (such as providing a history, filling out questionnaires about symptoms, etc.) directly into the system, which could make the clinical time with a health care provider more efficient and more personal, less focused on "data gathering."

Problems with EHR

Yet, there are a variety of problems associated with the use of computerized health record systems.  

Impact on Rapport

I think the worst problem is the potential impact on rapport during a health care visit.  If your physician or therapist is fumbling with a keyboard, and staring at a screen, instead of paying attention to you, this is poor quality of care, and threatens the therapeutic relationship.  This is potentially harmful to clients or patients, and is also potentially harmful to the well-being of the physician or therapist.  

You could compare this to having an "appointment" with a friend...if your friend is busy checking a cell phone or typing on a computer keyboard during dinner, or during a forest walk, the technology will harm your friendship!  When such behaviour becomes more frequent, more of a norm, more trendy, people tend to simply go along with such things, rather than insist that the device or gadget be turned off.  I think it would be better to complain to your friend about it instead, and to insist on having a conversation, or to insist on just walking quietly through the forest together!  

In some of the meetings I have attended over the past few years, I have seen people enthusiastically talking about new apps and gadgets in therapeutic settings (such as collaborating with clients using an ipad), yet part of the irony of these meetings was that the presenters or audience members were themselves so engrossed with their laptops or with their other gadgets that they had very little eye contact or social connection with those around them, and perhaps not a lot of awareness that their gadget-preoccupation was even a bit of an annoyance to their neighbours.  

Corporate Influence: 20 Billion Dollars!

Another problem with electronic records has to do with economic factors.   The EHR market is worth about $15-20 billion dollars globally, and is growing rapidly! *   This is enough money to fund 400 000 therapists, each earning $50 000 per year.

The corporations producing EHR software and machinery profit financially from sales. Clinics or hospitals using EHR will need educational sessions with representatives of the tech companies.  This is a potential conflict of interest issue:  it is similar to having medical education sessions organized and led by pharmaceutical reps.  The educational sessions are marketing opportunities for representatives of the EHR software company to consolidate adherence to a product.  Much of this education is sincerely useful for staff and beneficial for clients or patients, and the educational sessions may come with sincerely positive intentions.   But there are biases favouring a continuing business relationship with the software corporation, separate from considerations of patient or client care.  

Literature Review of EHR Problems

What does the academic literature have to say about this?  We have a pertinent article just published:  Susan Hingle, in Annals of Internal Medicine (Sep 6, 2016, doi 10:7326/M16-1757), reviews the use of electronic health records. Here is a quote from this article: 

Sinsky and colleagues confirm what many practicing physicians have claimed: Electronic health records (EHRs), in their current state, occupy a lot of physicians' time and draw attention away from their direct interactions with patients and from their personal lives. Observers documented that for every hour of direct clinical time with patients, physicians spent 2 additional hours on EHR and desk work, and physicians reported spending up to an additional 1 to 2 hours of after-hours personal time completing documentation and EHR tasks. These observations have important implications for patient care and outcomes...A recent study found that physicians who use EHRs and computerized physician order entry have decreased satisfaction and a higher risk for professional burnout. Physicians who burn out are at a significantly greater risk for depression and suicidal ideation, and there is also concern that they are more likely than satisfied colleagues to provide lower-quality patient care and to leave clinical practice early, although this is difficult to fully measure...Now is the time to go beyond complaining about EHRs and other practice hassles and to make needed changes to the health care system that will redirect our focus from the computer screen to our patients and help us rediscover the joy of medicine.

Here is another article, expressing similar concerns, from the Washington Examiner, published in October 2014 by Richard Pollock: 

http://www.washingtonexaminer.com/doctors-hospitals-rethinking-electronic-medical-records-mandated-by-2009-law/article/2554622

Another critical article, from the point of view of nursing staff in a hospital:
http://www.healthcarebusinesstech.com/nurses-ehr/

Here's a good article published in 2016 by Suzanne Coven, in Stat:
https://www.statnews.com/2016/04/06/electronic-medical-records-patients/

Despite these concerns, I do acknowledge the potentially useful role of computers, electronic records systems, therapeutic apps, etc.  But I think this gadgetry must never be focused on at the expense of highly personalized care for each client or patient.  As I have said elsewhere, I think these innovations can be truly great advances, but they can be a bit like giving children gifts at Christmas or birthdays:  children may get excited about a new toy, and may even become conditioned to expect more and more expensive toys as time goes by.  The toys may be great toys!  They could even be "educational"!

But the "gift" that children (and all the rest of us) really want and need is care and attention from loved ones.  Without this, the toys are worthless, and may even cause the children to have a deteriorating, materialistic quality of life.  

The impact of gadgetry and computers in health care affects not only clients or patients, but also caregivers, clinicians, therapists, and office staff.  It is important to consider staff quality of life, and staff satisfaction with work, as essential components in choosing health care strategies.  "Efficiency" and "optimal data collection" may seem to be desirable goals, but such efficiency is insidiously negative if it does not allow for a healthy workplace environment.  This is similar to managing a nation's economy:  a bottom-line view of maximizing economic efficiency may lead to increased overall financial wealth in a society; this is easy to measure, and therefore could be irresistible for policy-makers to follow.   But such optimization of efficiency and wealth can often lead to a decline in the morale and well-being of the population, if it is not balanced by other factors.  A reduction in efficiency, if it means more time for family, and better care of the environment, can sometimes lead to far greater wealth than anything money can buy.  

So in order to move forward with this issue, I do not suggest that we abandon EHR technology.  It is a potentially useful and innovative tool.  But we must never let our tools or toys distract us from providing a caring, empathic, human interaction.  We must never let a pursuit of efficiency or the acquisition of data have a higher order of importance  than caring, empathic, personalized health care. And we must be wary of corporate influences on health care policy, especially when large amounts of money are involved.

If you are affected by this issue, I encourage you to offer constructive feedback to your health care provider.     

Psychiatrists diagnosing public figures

I was reading an article today discussing the ethical problems involved when psychiatrists or psychologists apply a psychiatric diagnostic label to a public figure.

One big focus of objection in this article had to do with giving a "diagnosis" without actually seeing the person or doing a proper assessment.   Another concern had to do with the propriety of using a "professional voice" as a mental health care specialist to influence a political matter directly, possibly using diagnostic terminology that could have a pejorative quality.  In this case some of the terms of concern include "narcissistic personality disorder."

It's an interesting issue.  My addition to this debate may seem to support both sides of it!  First, I think it is somewhat arrogant on the part of psychiatrists to assume that they ever have some particular diagnostic wisdom, even with ongoing "assessment." Diagnostic terminology such as "narcissism" should be optional, informal language to be used, if at all, with the patient's consent and endorsement, for the purpose of helping the patient improve health.

One particular diagnostic label is arguably determined more exclusively by a person's observed behaviour, and that is antisocial personality.  Evidence about a pervasive pattern of past criminal acts, cheating, cruelty, etc. contribute to the use of the "antisocial" or "psychopathic"  label.  In this case, the motive of such terminology can go beyond that of offering the patient optimal care:  this type of "diagnostic" consideration relates to public safety, for example to evaluate the degree of risk a violent offender or abusive person might have to harm others in the future.

It may be that in some cases a professional such as psychiatrist might have more experience seeing people with potentially dangerous behavioural phenomena, such as antisocial personality, and have some ability to recognize and voice the risks associated with this.  With some cases of antisocial personality, it is possible for there to be an attractive and charming persona which can act as a sort of disguise, leading others to greatly underestimate risks.

I think it is deeply ethical to warn the public about such things.

But, I think it is unethical to wield a diagnostic label as part of some sort of pejorative, rhetorical attack against anyone.

I also think that specialists such as psychiatrists should be a great deal more humble about diagnostic opinions in any case.

A compromise, in my view, could be to voice general concerns about potentially dangerous behavioural syndromes, to share the opinion that such dangers can coexist with a charming and popular personality, and therefore to encourage great caution about following political trends, without very careful reflection on the cognitive biases that can occur in such situations.

This is the same kind of advice a marketing expert or a social psychologist might give to someone who is shopping for a used car...be well-informed about the risks!  The seller may have great integrity, but there is the risk of the seller only having a "facade" of integrity, and of telling you whatever you want to hear, in order to sell you a defective car at a disastrously high price.  There are some ways to be more accurately informed about such integrity, such as by considering patterns of past behaviour involving the person in question.

Psychiatrists should be able to speak freely about political matters, but there are ways to do this without a potentially unethical and inappropriate foray into diagnostic labels.

Sugar and Mental Health

There are a lot of people who make dietary recommendations.  It can be hard to figure out whom to believe.

There is a huge amount of money involved in food marketing, weight loss marketing and programs, and books about nutrition.  According to ABC News, the U.S. weight-loss industry brings in about $20 billion of revenue annually.  Another source claimed a worldwide market of a staggering $500 billion or more, for industries related to weight loss.

The issue of weight loss and food policy is a sensitive one, given the high prevalence of obesity as well as eating disorders in the modern world.   These nutritional and metabolic problems are associated with strong feelings of depression and anxiety, negative thoughts and belief about self, guilt, shame, and frustration.   Of course, there are life-threatening physical consequences of obesity as well as of other eating disorders such as anorexia. 

There are now some good documentaries available describing the history and dynamics of the food industry, particularly the industries which supply sugar and corn syrup.  For example, the films "Fed Up" (2014) or  "Sugar Coated" (2015) introduce the viewer to troubling information about large corporations sweetening the world's diet, despite abundant evidence of dangers to health.  The sugar industry has been compared to the tobacco industry, in the way that health concerns have been minimized or suppressed.   A lot of commercial advertising and other marketing directly targets children from an early age; many children associate various sweet food products with play activities, friendly cartoon characters, free toys, etc.  Some fast-food manufacturers sponsor health-related events or even resources for terminally ill children; while such charitable work is admirable, recent documentaries encourage us to consider it comparable to a cigarette manufacturer or a cocaine dealer sponsoring similar charities.   If we associate these companies with such altruism, we may be more apt to feel good about consuming their products.

Ironically, sugar itself is a required component of human metabolism.  Glucose is the main fuel for the brain.

Yet, the best way for the brain to obtain this glucose is from a diet low in sugar!  Pure sugar or other simple carbohydrates in the diet cause a sudden surge in blood glucose, triggering a cascade of hormonal changes.  Aside from the insulin response, there is a surge of pleasure from consuming sugar, which triggers an addictive behavioural sequence.

A habit of consuming sweetened foods leads to a reduction in the consumption of other nutrients.  As one develops a habit of eating sweeter things, non-sweet food items are likely to taste more bland.  It is hard for many people (especially starting off in childhood) to nurture a taste for vegetables when there are candies, ice cream, cake, cookies, or chips to choose instead.

As a component of improving mental and physical health, it is worthwhile to greatly reduce the amount of added sugar in the diet.  This reduction would be satisfying, not only due to direct improvements in your health, but also because you would be shifting your financial support away from a massively wealthy and arguably corrupt food industrial complex, towards a more wholesome industry of local farmers.

Smaller intakes of sweets and simple carbs are likely to improve your appreciation of the esthetics of other food.  Cutting sweets is not some kind of spartan sacrifice!  It will lead to greater joy and hedonic pleasure in your meals!  As you reduce sugar, your "addiction" to it will subside, allowing you to savour the tastes of all other foods, without the flavours being swamped by sweetness.  If you do end up having an occasional sweet treat, you will be able to enjoy it more thoroughly, with a smaller amount of sugar needed in the recipe.