Friday, February 24, 2017

Always Question

The freedom to question is a foundation of healthy living.

In our nation, we experience this freedom in the form of constitutional rights to express ourselves, and in the form of enjoying a free press.

For many of us, these freedoms may nevertheless seem fairly abstract, and maybe not that pertinent to daily living.  Other issues may seem much more important in daily life.  This is especially true if we are struggling with poverty, illness, or other consuming life stresses.  Sometimes there may not seem to be time to protect our freedoms, when there are other urgent matters to attend to.  Whole nations may feel the same way.

I would like to make a case that this type of freedom must be exercised, on a daily basis, in a wide range of daily activities.  This is not just a matter of protecting fundamental human rights, but it is a matter of thinking clearly and rationally about daily, practical decisions, so that we may make these decisions in a way which guides us towards better health and happiness, and education.

Once again, I would like to refer to the work of the great psychologist and Nobel laureate, Daniel Kahneman:  he showed us how the human mind is deeply prone to cognitive biases, which affect all of our decisions, often outside of our conscious awareness.  His work also suggests ways that we can protect ourselves from being misguided by our biases.

Let's look at an example situation, of a public educational lecture.  How do biases occur in such a setting, and how can we exercise our freedoms in a healthy way as audience members?

Most of us would understand a public scholarly lecture to be an entirely benign educational event, in which we could all expand our minds...this would be especially true if the speaker were articulate, expressive, passionate, and experienced with giving lectures!

But here are a variety of biases that occur in lectures:

The Focusing Illusion

In order for a lecture to be narratively interesting, it should probably have a "thesis."  This is not unlike a well-written essay (actually, this is one of the ethical problems of the conventionally encouraged format of essays that most students are called upon to produce).  If the speaker is vacillating between several positions, the audience may view him or her as weak-minded or lacking confidence.   An essayist who vacillates will probably receive a lower grade.

But in order to propose a single thesis, we already are at risk of a bias called the "focusing illusion."  This is akin to experiencing a salesman trying to sell you a used car, or a vacation package, or a set of encyclopedias, or an opportunity to contribute to a charity:  if we are presented with one single thing, whether it be a consumer item or an idea, we are more likely to accept it, compared to being offered a variety of options, each given equal time and persuasive effort.

A lecture, even if it is being given by a famous, experienced, wise scholar, is quite possibly biased due to the focusing illusion.  The audience is more likely to accept the message of the speaker, beyond the acceptance that would be reasonable based on rational thought alone.

Cialdini's Persuasive Factors

Cialdini described the following elements which magnify persuasive power, beyond the rational content of any message or appeal:
a) liking  b) authority c) social pressure d)consistency e)reciprocity f)scarcity

A public speaker's persuasiveness will be bolstered by a wide variety of elements which have nothing to do with the accuracy or content of the thesis.  An enthusiastic or passionate speaker who is a well-liked and respected authority (or who at least seems to be), will have greater power to persuade an audience, irrespective of the content of the lecture.    If many others in the audience are enchanted with the speaker, and are smiling, nodding, or applauding, then you as an audience member will be more likely to go along with this spirit of approval, through social pressure.

A speaker who is wearing more expensive clothing,  who physically looks more like you, or has some other coincidental common background (such as hometown, ethnic heritage, or cultural interests),  has a more attractive video presentation, with more attractive fonts, elements of humour, and perhaps musical accompaniment, is more likely to be persuasive.

  If you have already agreed, particularly in a public way, or through agreements made in previous meetings, to elements of what you are hearing in a current lecture, you are more likely to go further with what the lecturer is saying, even if you would have otherwise disagreed.  This is due to the factor of consistency.  If you are served snacks and coffee during the lecture, and if the speaker gives you warm compliments, you will be more persuaded by the speaker's message, due to reciprocity.   And if the speaker is heavily booked across North America, and if it was hard to even get a ticket to attend the lecture, then you will be more persuaded, since the lecturer will seem more rare and special (scarcity).

Suppression of Counterargument

Kahneman and others have made the case that the most powerful persuasive bias of all is caused by suppression of counter-argument.

If you are attending a lecture, a presentation, a meeting, or a political rally, in which opposing views are not allowed, then this is a strongly loaded environment for biased persuasion.   We have seen this phenomenon in political rallies across the world in the past year.  When dissent is discouraged, suppressed, or even forbidden, then we as individuals, and we as a society, have lost our authority to make free decisions.  Decision-making under such conditions cannot be rational.  It would be like a court case in which only the prosecutor or defense would be allowed to speak, rather than allowing both sides an equal opportunity.  Or, imagine a NASA team designing a new space station, in which it was not encouraged for engineers or technicians to express concerns about design flaws or safety issues.

Sometimes counter-argument seems to be encouraged, but the actual time and space for this to occur is not actually present.  It is freedom in word only, not in action--which really is not freedom at all.  A lecturer may allow some time for questions or debate, but often only a few minutes near the end.  And the old familiar forces, stated above, may subtly suppress debate.  Most audience members would consider it impolite to express disagreement with the speaker, especially if dissenting comments would receive negative non-verbal feedback from fellow audience members.

Zimbardo's Heroism

Philip Zimbardo, another great psychologist of our generation, has made it part of his life's work to study negative behaviours that occur in groups, in conjunction with the types of social psychological dynamics (such as group persuasion) that we've discussed above.

He calls for us to be "heroic":  what he means is that we should truly exercise our freedom, to always question.   It is easy to question things when we are strongly invited to do so.  It is harder to practice this freedom in an environment where questioning is discouraged.

The Risks of Questioning

If you raise questions, it is possible that you could get criticized by others in the group around you.  You might be labelled as being difficult, oppositional, or disloyal.  Some people may believe that you are being resistant to change, stubborn, or disrespectful.   Some might even think you are being narcissistic, as though you are aggrandizing your own opinions while devaluing the opinions of others.  The fear of such group disapproval, or of receiving such labels, often deters people from speaking out about things that need to be said.  

I think this is a risk worth taking.  You can show in other ways that you are not difficult, oppositional, disloyal, disrespectful, stubborn, or narcissistic.  The process of freely questioning actually prevents such problems...because freedom of speech, particularly when used in the service of ethical principles and practical problem-solving, causes a growth and strengthening of healthy character traits, both in the individual, and in the group.

I have experienced this type of dynamic, to my surprise and dismay, this past year, and I have decided to try to use this blog as a vehicle to practice and encourage free speech in this way.

Relevance to Psychotherapy & Mental Health

All mental health problems could be understood, in part, to reflect a lack of freedom.  Symptoms, such as anxiety or depression or insomnia or fatigue, may limit our freedom to experience life in a meaningful, enjoyable way.

Practicing our freedom of expression is an integral part of cultivating mental health, on a personal level.  This freedom could occur, for example, in the form of being able to initiate a conversation which was previously suppressed due to social anxiety or low self-esteem.

In therapy, the counselor or psychiatrist is an authority figure, but this force of authority should not be something that suppresses free expression.  Rather, the therapy environment should encourage freedom, including the freedom to dissent!   It should feel ok to completely disagree with your therapist, without fear of rejection or argument!   I think it should be accepted that it would also be ok, or necessary,  for your therapist to sometimes continue a gentle debate with you, rather than simply agree with what you are saying all the time.   But this dialog must occur with kindness, compassion, and respect, in a spirit of true openness.

If you are a student, or a member of the audience for meetings, sermons, or lectures, I encourage you always to nurture your freedoms, and to exercise your right to question.  It will not only be of great benefit to you, but it will be of great service to other members of the audience, and to the educational process.

Cognitive Therapy

At its best, cognitive therapy is a formal mechanism to question one's own thoughts!  Anxiety, depression, trauma, and other adversity give rise to changes in thought, which can often end up causing suffering or oppression.  If your own thoughts are frequently bullying you, putting you down, or telling you that you can't do certain things, then this is akin to attending a biased presentation at a lecture, political rally, sermon, or policy planning meeting.

Negative thoughts often could be understood to have some positive motivations--with many anxious thoughts, there may be a sincere motive to be protective.  Your thoughts may be trying to warn you about potential dangers, based on learning from the past.  It is just that the voice of these thoughts can become too powerful and persuasive, like a demagogue at a political rally.

These negative thoughts are bolstered by the same familiar factors described above:
1) negative self-talk is often presented without comparisons -- leading to the focusing illusion
2) negative self-talk can seem authoritative, which makes it more believable
3) negative self-talk may have been around for a very long time, which bolsters the persuasive factor of "consistency."  You may have even made certain "commitments" to the negative thought, or perhaps have been using them as motivational tools (e.g. studying to avoid guilt, rather than to pursue joy).
4) negative self-talk often does not invite questioning or dialog in your likes to have the final word...attempts to question it can seem futile

So, cognitive therapy can be framed as a type of personal liberation movement, which requires a practice of active questioning.  You can become a civil rights leader in your own mind!   I think it is important to view cognitive therapy exercises in this way, as the techniques can otherwise seem somewhat oppressive in themselves...the point in cognitive therapy should not be simply to do the exercises your therapist or self-help book is prescribing for you, or to criticize your "cognitive distortions"--this sounds disturbingly like the type of talk yet another oppressor might use.  Analogously, in many oppressive political systems, we see one tyrant simply being replaced by is necessary instead to strive for freedom.   So I encourage your work in cognitive therapy to be an exercise in compassionately  developing and asserting your freedom, through courageous questioning of your self-talk.  

I am not meaning to encourage reflexive defiance, however.  Sometimes, after a period of debate, it is time to make a decision, and to move forward with that.  It can be unhelpful to debate every step of the way in every change process or learning event.  But it is very important to make sure that there is space and time given, in all situations, for freedom of speech, free opportunity for dissent, and for balanced, unbiased decision making.  I encourage you to protect your own freedoms this way, and also to protect the freedoms of others, by practicing a lifestyle of intellectual openness, curiosity, and free questioning.

Tuesday, February 7, 2017

Mediterranean Diet for Treating Depression

Jacka et al. have just published in BMC Medicine (January 30, 2017) the results of a study showing that healthy dietary change leads to significant improvement in depression.

In their "SMILES" study (another astonishing acronym--it stands for "Supporting the Modification of Lifestyle in Lowered Emotional States" !!), they included 67 people with moderate to severe depression, who also had low dietary quality (e.g. they were not eating a lot of vegetables, fiber, fish, and nuts, but were eating a lot of processed foods and sweets).  The participants were randomized to receive 7 sessions of either nutritional counseling, or social support.  The nutritional counseling aimed to encourage a Mediterranean-style diet, including whole grains, nuts, fish, legumes, vegetables, and fruit, while avoiding sweets and processed foods.  The social support involved having neutral conversations or playing games ("befriending").

People in the nutritional counseling group dropped their depression rating scores by about 40%, while scores in the social support group dropped by only 20%, which was statistically different with a p-value of about .03.  That is, the difference in outcome was about 97% likely to be due to the treatment effect, rather than to chance.

Reflection and Conclusion

It goes without saying, in my opinion, that healthy diet must be emphasized for everyone, in order to improve all aspects of physical and mental well-being.  In depressive states, nutrition tends to be less healthy, for a variety of reasons:  people may have less energy to attend to good nutrition; their depression may cause reduced or increased appetite; there may be comorbid eating disorders; there may be medication-induced side effects affecting nutritional behaviour or metabolism; and the depression could be associated with negative economic and social factors, which are in turn related to poor nutrition.

In addition to this, it is possible that there is a direct biological effect of poor nutritional quality causing depression.

So, in order to manage depression, and all other illnesses, it is of course important to encourage healthy dietary change.

But in the case of this study, there are a few ways in which the results may seem to exaggerate the effect of the nutritional change:

First, it seems to me that any substantial positive lifestyle change could have an "active placebo" effect independent of its direct effect on mood.  Changing your diet in the ways suggested is, in my opinion, intrinsically healthy.  But in order for someone to actually make these changes, they would have to frequently make different decisions than usual in the course of their day (for example, they would eat broccoli and fish instead of a fast food burger).  It is clearly healthier to have that broccoli and fish, but the therapeutic impact of this decision may not be exclusively because of the better nutrition--it is also because the person is taking an active, disciplined step to choose something deliberately, in the name of changing their life for the better.  It is this positive intention which may be a significant part of the therapeutic impact.

People in the control group, who had conversations and card games during the 7 sessions, probably did not experience much of a sense of their lifestyle substantially changing.  I think a more interesting activity for the control group would involve something similarly "lifestyle changing" but not following the same nutritional guidelines.  

So I wholeheartedly affirm the practice of making positive dietary changes!  I have seen numerous patients who are feeling better as a result of making similar changes themselves.  But it is also important to question the conclusion of studies like this one...Here's a reason why:  suppose that there was another study which showed that buying an expensive nutritional supplement led to similar improvements in depression scores.  The supplement, in reality, could be inert, or could simply be flavoured water.  But taking the supplement would require a very active commitment on the part of participants, to alter their dietary behaviour in a consistent, disciplined way, with enthusiastic support from people claiming to be experts, over 12 weeks.  In this case, we could agree easily that the therapeutic impact of the apparent nutritional change was due to a change in disciplined habits, combined with positive expectancy, rather than due to the wholesome properties of the supplement itself.  If people were to assume, erroneously, that the supplement (and not the discipline involved to take the supplement) caused the benefit, then people would be at risk of being taken advantage of financially by the supplement manufacturers.
In conclusion,  I strongly encourage that people make positive, disciplined, healthy dietary change.  It quite probably will improve all aspects of health, including mental health.  But be careful not to overvalue the results of studies such as this one, since the same reasoning that would allow you to uncritically endorse this study's conclusions could make you vulnerable to the persuasive efforts of marketers selling products which also require disciplined adherence.

Wednesday, February 1, 2017

Compassion vs. Empathy: Reflections on Paul Bloom's Book

Paul Bloom, in his recent book called Against Empathy, challenges us to question the role of empathy as a vital ingredient of goodness or morality.  Bloom believes that kindness, guided by thoughtfulness, is the supreme guide to morality, while empathy is often morally neutral or even negative.

Bloom's definition of Empathy

By "empathy," Bloom is specifically referring to the phenomenon of experiencing and feeling what another person is experiencing and feeling.    Many of us define empathy more broadly, so as to imply kind consideration for others' distress, a willingness to help, and an intellectual understanding of another person's problems.  Even some of the researchers who study empathy are imprecise in their definition, leading them to include items about kindness or willingness to help on a symptom scale supposedly intended to measure empathy.

Bloom clearly is not talking about "understanding."   He affirms that it is clearly and obviously important to strive towards understanding of another person's problems or situation, in order to be able to best act morally and helpfully.    A variant of empathy, which we could call "cognitive empathy," refers to understanding, but not feeling, another person's emotional state.  Bloom affirms that this cognitive empathy is important and positive as a social skill, but is not necessarily a guarantee of moral behaviour.   With Bloom's specific, narrower definition of empathy (to feel what another person is feeling), he shows us the following:

Problems with Empathy

1) Empathy does not correlate with kindness.  Many people who behave cruelly have a lot of empathy for their victims.  In fact, sometimes the empathy for the victim causes a sadistic person to magnify their cruelty.  A good fictional example is the character of O'Brien (the "Big Brother" agent) from Orwell's 1984, whose emotional and cognitive empathy guided him to personalize and maximize his torment of the main character.

Conversely, some people who behave with the most astounding kindness and altruism are not guided or motivated by empathy at all.   People who perform daring rescues often do not empathize before they act.  Having an empathic reaction in an emergency could delay a life-saving action.

One example is described of a person who chose to give his kidney to a stranger for a transplant, guided by a cooly mathematical observation of the needlessness of having two kidneys for health, while many people would face death without a single kidney.    People, including young children, are usually motivated to do kind things not because of empathy, but because of a wish to be kind or helpful!

Empathy can actually deter people from behaving kindly, or from even being around suffering people, because the experience of feeling another's suffering is painful and aversive.  A caregiver who is highly, reflexively empathic is at greater risk of burnout.  Whole groups of people, such as those who identify as having autistic symptoms, may have much less "empathy" than average, but they are not at higher risk of causing anyone harm.   Violent offenders do not necessarily have "low empathy"-- the psychological factors associated with violent behaviour have much more to do with low self-control than low empathy.

2) Empathy as a moral guide can cause us to behave in a biased or unfair manner.  If we use only empathy to guide us to help a particular suffering person, it can guide us to help that person before helping someone else who needs the help more urgently.    Furthermore, we empathize more easily with people who are more similar to ourselves, and who live closer.  This may cause us to preferentially help others based on unjust factors (including age, race, ethnicity, etc.).   It is easier to empathize with a suffering animal we find "cute" compared to a suffering animal (who may be in even greater need) who is less photogenic.

Bloom rightly critiques the tendency for empathy to be admired as a type of stellar quality, for all of us to emulate in a quest to become better people, better therapists, or better societies.  He instead encourages us to strive towards kindness and understanding, with our actions guided by reason rather than the narrow, biased focus of emotional empathy alone.  This view is supported by those considered some of the world's greatest altruists, such as the Dalai Lama--in this tradition, it is calm compassion, free of anger, which is felt to be the best guide for moral action, rather than the emotion-swept milieu generated by empathy.

My Thoughts

I see Bloom's thesis as an extension of Kahneman's insights about psychological biases.  Our biases and emotional responses are an intrinsic part of being human, but they easily become experiences which fool us, and cause us to behave irrationally.

Empathy, in my opinion, is a quality similar to eyesight or one of the other senses:  it does not, in itself, have a moral quality.  It can have a narrow focus, which makes it prone to bias, and it can be easily fooled by illusions.  Having highly developed empathy does not make you more moral any more than does having sharp eyesight.  If you believe strongly that your sharp eyesight allows you to understand things better, you may be very prone to others taking advantage of your belief, and you may be very prone to being fooled by optical illusions.  This does not mean we should not cultivate our senses, including eyesight or empathy.  They are important talents and skills, and they deserve attention and practice.  It is just that we should not rely on them by themselves as moral guides.

Taming Empathy

I do believe that empathy is important, however.  It just needs to be "tamed."  I can think of many clinical situations in which an empathic moment--even to the point where I might shed a tear--has helped with my patient feeling a sense of connection and trust.   A therapist who shows no emotional response to a patient's suffering could be experienced as detached, aloof, and cold.  Also, many therapists have a reflexive suppression of their own affect, which is felt to be a part of professionalism, yet which causes an unnecessary and obstructive detachment.   A therapist's practice of allowing their own emotions to flow empathically, and to manifest in the session, can be an aspect of fostering connection and demonstrating sensitivity.   But if this empathy would lead to the therapist suffering with sadness or panic through the hour, at the same time as the patient, then this clearly would not  be helpful!  It would probably frighten or disturb the patient, and would also lead to burnout in the therapist.   A brief moment of deep empathy can be very therapeutic, but after that point, therapy moves away from pure empathy towards cognitive understanding and gentle problem-solving.

Empathy can also be a joy of life to experience, provided it is not understood to be a moral guide.   Empathy can and should be practiced and savoured, just as you would cultivate your other senses--but it should not be granted power as an arbiter of moral decisions.

Empathy for the Therapist! 

Bloom makes a nice point that in a good therapeutic environment, sometimes empathy is most beneficial in the opposite direction:  if the therapist is gently attuned and understanding, but calm and at peace, then the patient's empathy for the therapist may help the patient to attain calm and peacefulness in the midst of painful emotions.

Empathy could work this way in therapy as an example of social learning therapy combined with CBT:  if the patient would see the therapist briefly having a deep empathic moment of "co-suffering," but would then see the therapist gently step back, in a thoughtful, compassionate calm state, this could be an in-the-moment example for the patient to this way the therapist would truly be an emotional guide.  I think this effect should not be overstated, as the therapist's helping role may usually be much more modest and subtle.

The Importance of Listening and Showing Understanding

I believe it is very important to emphasize that we have been talking about Bloom's very focused definition of empathy.  I usually use the term empathy in a broader sense.    When people are meeting with a therapist or a friend, they often greatly desire to simply be with someone who will listen.   Many people do not desire to have advice or reassurance in response to what they are sharing, at least not right away.  And they may be frustrated if the other person starts to discuss their own similar problems.   It is often very appreciated if the listener at times reflects back what has been said, to convey respectful understanding, of both the situation and the emotions involved.  This reflection and demonstrated understanding is what I mean by empathy, most of the time.  A typical example could be saying something like, "you had an exhausting day..."  When giving this reflection, I would not normally feel exhausted myself!  Sometimes a more elaborate or detailed reflection could be good, but sometimes prolonging these responses for more than a brief sentence can interrupt the person's experience of being gently listened to.