Garth Kroeker: Search results for against empathy

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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 follow...in 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.

Thursday, February 26, 2026

The Psychology of Religion, Chapter 18: Prayer

Prayer may mean different things to different people. For many, it is a meditative act: a type of philosophical reflection with existential themes, a kind of relaxation therapy, a “grounding” moment. The praying person may believe they are having a conversation with God. The manner in which God is understood to speak back is often taken in a broad, figurative way—for example, if the person subsequently has a new idea, an inclination, a redoubling of confidence, or a wave of emotion that feels like guidance. Other people may not expect that God will “speak back” at all; they may be content simply to vent, confess, grieve, or reflect within a reverent framework. In some ways this resembles classical psychoanalysis: the listener is largely silent, and the act of speaking—slowly, honestly, repeatedly—becomes the mechanism.

For many people, prayer is simply reflective or meditative: a grounding moment, a way to name fears and hopes, a way to feel less alone. But many people also pray for things—for an outcome to change, for an illness to heal, for a surgery to go well, for a war to end, for a relationship to mend. That kind of prayer is different. If it is literally effective, it would mean that events in the physical world are being altered—something in the normal chain of causation is being nudged off course. And if this were happening in a consistent, repeatable way, you would expect to see clear clusters of unusually good outcomes in places where people pray the most, or where the “right” kind of prayer is supposedly most common. You would expect the world to look, especially in more religious areas, as though the ordinary rules of physics are being bent on request. I am not aware of any such pattern.

When researchers have tried to test this carefully—especially with “praying for someone else” (intercessory prayer)—the results have not produced a solid, repeatable signal. A well-known example is the STEP trial in cardiac bypass patients: people were randomized to receive or not receive intercessory prayer, and another group was told with certainty that they were being prayed for. Overall, prayer did not reduce medical complications. Interestingly, the group who knew they were being prayed for actually did a bit worse: complications were reported in 59% of those certain they were receiving prayer versus 52% in a comparison group. One plausible explanation is psychological: once a person is told “people are praying for you,” it can quietly raise the pressure. What if I don’t get better? What does that mean about me? About God? About my faith? For someone already frightened and vulnerable, that extra layer—expectation, scrutiny, the sense that a spiritual “test” is underway—can add stress rather than comfort.

The moral structure of prayer often mirrors the moral structure of empathy. Many people’s prayers are genuinely compassionate: they think of struggling friends or family members, or of terrible world events, and they ask for comfort, protection, and healing. But if prayer is believed to cause divine comfort to arrive, this raises an uncomfortable counterfactual: if the prayer had not occurred, would comfort have been withheld? And shouldn’t a loving deity comfort suffering people regardless of whether someone happens to pray for them—especially since some of the worst suffering on earth occurs in isolation, unnoticed, with no one else even aware enough to pray? It suggests a troubling arrangement where God’s help isn’t based on who is suffering the most, but on who is lucky enough to be noticed.

This is also where it helps to remember Paul Bloom’s critique of empathy (see my review of his book, Against Empathy). Empathy is often biased and therefore unjust: it is pulled toward people who resemble us, toward vivid stories, toward those whose suffering is emotionally dramatic, while neglecting the quiet, the distant, the stigmatized, and the statistically larger tragedies that do not come with a single tear-streaked face. Prayer often inherits this same distortion. We pray intensely for the salient and familiar, and far less for abstract fairness, or for the invisible victims who never make it into our attention.

Many prayers are not about others at all; they are about wishing something for oneself. There are battlefield prayers. Prayers before a medical procedure. Prayers for money, for a job, for the return of an ex-partner, for relief from chronic pain, for the outcome of a baseball pitch or a hockey game. As a meditative act, this is deeply understandable. But psychologically it can set up a reinforcement loop: if the prayer is followed by a good outcome, the person will naturally feel it “worked,” and will be bolstered to pray again. If the outcome is bad, the person may conclude they didn’t pray sincerely enough, or long enough, or correctly enough—or that God was busy, or displeased, or testing them. Either way, the practice becomes insulated from disconfirmation.

This helps explain why prayer works psychologically, even if the supernatural claims aren't true. As a form of meditation or reflection, it can be calming and help organize our thoughts. But as a way to change the laws of physics or alter the course of events, it functions as a self-reinforcing loop. When a prayer is followed by a desired outcome, it is taken as proof of God’s power. When it isn't, the failure is easily explained away—either God said 'no,' or we didn't pray with enough faith. This dynamic validates the belief system regardless of the result, but it places an immense burden on the believer—creating the stressful illusion that their personal spiritual effort is the decisive factor in changing reality.

Sunday, June 9, 2019

Review: "The Righteous Mind" by Jonathan Haidt

I recommend this book.

In The Righteous Mind, Jonathan Haidt shows that different people have different foundations which underlie their moral judgments or beliefs.

On the "left," the foundations of fairness and charity are more prominent. On the "right," the foundations of loyalty and "purity" are more prominent.

These styles or foundations may be propagated in culture or family upbringing, but also are partly influenced by heredity (genes). In the middle part of the book, Haidt argues that each of these moral foundations can convey improved survival or natural selective advantage to whole groups. For example, a group which values loyalty very strongly as a moral foundation is more like to be cohesive, and therefore more resilient to various stresses, including warfare or internal discord.

Haidt concludes his book with a strong message that we should empathize with people or groups which have different moral foundations, rather than simply fight with them or view them as enemies. He espouses the goal of befriending opponents, including those who have different political or religious beliefs or moral foundations. Such friendship would then reduce extremes of polarization and conflict, and allow groups to move forward more peacefully.

I respect his thesis very much, of cultivating understanding and empathy for people or groups which have different moral, religious, or political beliefs than one's own. In a psychotherapy environment, such empathy is required in order for progress to occur, even when the therapist may object strongly to aspects of the patient's behaviour.

But I have some criticisms of Haidt's thesis:

Haidt seems to disparage the importance of reason or rationality. In a type of "straw man" argument, he suggests that "reason" without other moral foundations such as loyalty, is insufficient or even pathological. He uses a metaphor of a person or a mind being like an elephant, a powerful creature guided by instincts and passions, with the "rider" of the elephant being our "reason" or logical faculties. The "rider" is described as a recent evolutionary development, intended to serve the elephant, rather than rule over it.

He anticipates in the book that some people will disagree with him on this. I certainly do. I do not disagree that the development of sophisticated reason or rationality is a recent development in evolutionary history, that it indeed did develop in service to the "elephant," and that there are strong selective advantages for "non-rational" qualities, which remain prevalent in nature. But the evolutionary presence of traits is not evidence of their high moral value.

Modern rationality is the foundation of the justice system. Imagine a court system, a scientific lab, a factory producing safety equipment, or a spacecraft agency such as NASA, which would not hold reason as the highest foundation in its decision-making, but instead would consider "loyalty" or "purity" as most important. Such foundations would, and often have, led to disaster.

I realize that some applications of reason may in retrospect prove not so "reasonable" after all. Reason is always fallible, and can be the foundation of huge mistakes--not just technical failures due to mistaken ideas that were apparently well-supported at the time (e.g. the belief in medical remedies such as bloodletting), but also moral catastrophes. But the process of reason requires it to be flexible, to monitor itself for mistakes, to be willing to make corrections when new information arises. This differs from "loyalty" which is by definition resistant to change despite the arrival of new information.

"Loyalty" could be considered a component of "reason" which requires a waiting period before acting on new ideas. It could be like electing a senator for a 6 year term, with other representatives elected for 2 year terms. The senators would be more resistant to rapid or erratic whims of a capricious populace, while the representatives would be poised to act more quickly; the two chambers would ideally lead to an effective equilibrium, sensitive to change, but not impulsively so.

I am not saying that "loyalty" or "purity" are unimportant, but they cannot be viewed as morally equivalent to reason, on some kind of equal footing, such that differences between people can be understood simply as cultural variation.

I was bothered in Haidt's book by his passing disparaging reference to "new atheists" such as Richard Dawkins, more or less dismissing the value of their ideas without acknowledging their wisdom or contribution. There are major problems with these thinkers which warrant fair criticism, but they do deserve respect and attention. This is ironically contrary to Haidt's best conclusion, which is to have some empathy and respect for viewpoints different from one's own.

I am more allied to scholars such as Steven Pinker or Paul Bloom, who are "rationalists" in their approach to psychology and morality. But I have to admit that Jonathan Haidt is an important thinker as well, and deserves respect and attention.

Any author of a book has a tendency to have some inflexibility in their position afterwards, due to several psychological biases. If you have publicly asserted a position, and have become famous for it, you are more likely to maintain it in order to appear consistent, even if there are good arguments against it. There can be some degree of ego involved as well--people don't like to admit that they are wrong. I wish there was a little bit more humility when scholars or experts assert positions on these issues.

I am not an author (except for this modest blog), but I know that I have an ego as well, and I would have a tendency to defend positions that I have asserted, even when they may need to be changed or adapted. I need to watch this tendency in myself, as we all do in ourselves.

In some cases, it may not be possible to have a friendly, empathic dialogue in a setting of conflict, oppression, or injustice. Haidt does not explore this type of scenario adequately. Friendship and empathy are neglected in the management of conflict and polarization, but it is important to acknowledge as well that some of the necessary forces of positive change and justice can be rather more difficult and conflict-ridden.

Thursday, July 31, 2025

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Friday, December 10, 2021

Wednesday, August 20, 2014

The Better Angels of Our Nature: Why Violence Has Declined, by Steven Pinker: A Book Review, Part 2

The first section of Pinker's book is an exhaustive review of violence rates throughout history. This even includes looking beyond our own species, to other great apes, to understand aggression in our evolutionary lineage. He also reviews cultural attitudes towards violence throughout the ages, as manifest in literature and the arts, and also in accounts of daily social and entertainment practices. It is very disconcerting to learn about the extent to which horrifying acts of cruelty were commonly accepted, or even considered amusements (the events in the Roman Colosseum comprise just one of many, many examples)

Clearly, rates of violence were much, much higher in all previous periods of history. Today the risk of suffering a violent non-suicidal death (from war or other crimes) is in the order of 1% or less (this is the total risk over an entire lifespan).    In most prosperous areas of the world it is much less than 1%. Of the 245 000 deaths in Canada in 2012, 543 were due to homicide (0.2 % of the total).link   link2

But in all previous eras of human and pre-human history, these risks were orders of magnitude higher, according to a variety of streams of evidence which Pinker amasses. Instead of 0.2%, the rates were 10% or more.    If anything, much of this data may actually underestimate these past rates, since violence was so much a norm in previous periods of history that many violent deaths or even massacres were barely mentioned in historical texts. Risks of non-homicidal violence were much higher still, such that most everyone in the population would have been traumatized in some way, or would have had a close friend or family member who was severely traumatized.

Pinker outlines various of the forces which have driven violent behaviour over the ages; here are some of them:

1) predation
2) dominance
3) revenge
4) communalism/tribalism/nationalism
5) sadism
6) isolation
7) authoritarianism
8) ideology
9) lack of intelligence

1)
Predation is described as a simple goal-oriented motive, such as robbery or looting. Yet this strategy is "zero sum" or "negative sum" in that there is no net gain during a robbery, only a transfer of property, and most likely a destruction of the means to efficiently produce more property (e.g. jewelry may be stolen in an attack, but the infrastructure or morale needed to produce more or better jewelry gets damaged in the process).

With societal evolution, free trade becomes a non-violent alternative to predation, which allows the process to be "positive sum." In this case, goods could be traded for jewelry, leading to a prospering group of jewelers who can then produce more or better jewelry in the future. Both parties gain.   In order for free trade to occur, and the ensuing reduction in predatory violence, there must be improved communication, a fairly governed commercial system, and penalties for predation which are agreed upon by both parties.

In a psychotherapeutic milieu, this principle could lead to the idea of improving communication and stable transactional rules between potentially conflicted individuals. In general, the idea of trading with your enemy instead of fighting your enemy may not naturally occur to people.

Pinker does not adequately discuss some of the problems with trading relationships, and of free-market economics in general. Such relationships can be imbalanced, exploitative on some level (either directly towards the individuals or nations involved, or towards the environment), or favouring a relatively small elite while having little benefit for the majority. I think there needs to be more emphasis on "fair" trade, including a strong focus on environmental issues. This is consistent with Pinker's observations about the need to expand a "circle of empathy." This circle should expand to include not just trading partners, but the larger communities affected by trade, and the benefits or consequences to the natural environment. Trade may often benefit the environment, through a simple economic efficiency argument: the lowest-cost economic solution to a problem is favoured by free trade, which in turn can maximize the available eonomic resources to protect the environment. But in order for this efficiency to be protective, there needs to be structured safeguards in place to prevent social or environmental exploitation. Another big issue I have found with conventional economic theory is that costs are underestimated (such as long-term environmental damage), and the cross-sectional cost appears to be very low; often those involved are not held responsible for the ultimate long-term costs. In any case, this inaccuracy in measuring costs distorts the system, and causes it to be short-sighted.

2)
Dominance contests can be seen in many species, often as part of a competition for mates. Most often, of course, these are behaviours seen in males. In humans, this can give rises to meaningless displays of strength or machismo, with an associated culture of "honour" in which small perceived slights can result in excessive aggressive reactions. Associated psychological phenomena include overconfidence, underestimation of the losses associated with the conflict, and of course lack of empathy for the opponent. In celebrating a culture of "glory and honour" there can be an utter disregard for the individuals and families affected by the ensuing violent losses.

If this type of behaviour is selected for in the population, it gives rise to large, aggressive, arrogant, reckless males who are easily provoked. In other species it can give rise to males having harems with multiple mates, while driving away or killing other male challengers (we see literal examples of this in human groups throughout history).

In humans, this type of dynamic can occur in "honour-based" cultures; previous periods of history often featured distinguished gentlemen absurdly fighting to the death in duels, often over trivial conflicts. But entire nations can behave in this fashion as well.

Improvement in this type of problem comes with greater education, strong emphasis on women's rights and gender equality, and selection pressure: reckless, aggressive males with poor impulse control are much less likely to be found attractive as mates in the modern era! Instead, most elements of modern culture favour self-control and a culture of "dignity." It is no longer cool or attractive to be a bully or a hothead.

3)
Revenge is an understandable reflexive process, and it is pointed out that some degree of revenge can be a deterrent to subsequent violence (to show no revenge can invite subsequent exploitation). The problem with revenge, as Pinker shows, is twofold: first, wronged individuals or states tend to want to deliver more punitive harm than a neutral mediator would prescribe. The individuals doing the wrong likewise tend to underestimate their culpability or guilt (e.g. a great many convicted felons may have a smaller estimation of the magnitude of their guilt or responsibility for harm than a neutral observer or their victims would conclude). This leads to a cycle of revenge, in which each group retaliates vindictively against each other, with force that is often out of proportion to the offense, and each wrongdoer underestimates their culpability.   The retaliation is itself therefore felt as an assault by the recipient, rather than as a fair punishment. The violence therefore continues in an escalating fashion, with each group feeling justified in their actions, egregiously wronged by the other, and with each group inducing future acts of vengeance from their enemies.

The solutions to this predicament include having neutral arbiters--a fair system of policing and justice, empowered by a neutral and fair government which has a motive of minimizing overall harm in its citizens.

On a psychological level, a solution is to recognize the cognitive biases which lead to excessive retaliations and excessive justifications for one's own excesses. Another solution is to recognize the need for neutral mediation to help resolve ongoing conflicts.

4)
Communalism, tribalism, or nationalism are understandable, common human experiences. Early human culture required a cohesive sense of protecting one's fellow villagers from attacks from neighbours. Yet, tribalism fosters patterns of revenge, predation, and dominance-based aggression on a group level. Having separate tribal cultures, often with language and geographic barriers, is a barrier to empathy for outsiders, particularly if a cycle of warfare has already begun. We see this type of aggression on a large and small scale, all around us. In some cases it is playful, as in sports teams from different communities. Gang behaviour in large cities has a tribal quality, with battles over control, protection, predation of resources, and "honour." But entire nations behave this way. We subjectively have an urge to enjoy national identity, but we have to be wary of the violent associations of this mindset.

An approach to this issue is to expand our "circle of empathy," and to view those from other groups as partners rather than enemies. I suspect the healthiest vestige of nationalism that we can safely keep is to have sports teams. I think this is also a reason to support free, fair international trade. Protectionist policies must be based on a notion that there is an "us" and a "them". But it is fair to view everyone in the world as part of "us" at this point.

Nationalist conflict is one of the most devastating factors causing worldwide violent death and suffering through the ages.

It is for this reason that I support the idea of having international sports events -- I believe that this is a symbolic peaceful sublimation of nationalistic conflict, transforming this type of tension into a playful harmless talent show.   The economic indulgence of such events, such as the Olympics, is an understandable complaint, but I think the pursuit of such playful, peaceful activities is very important.

5)
Sadism may seem like a rarity, relevant only to extreme cases. But smaller forms of this issue can occur in communities or in one's inner life. The driving force in sadism is addictive: repeated behaviours, even if extremely harmful, can lose their aversive or "taboo" character through repetition, and even lead to addictive pleasure, associated with excitement, relief of tension, etc. This phenomenon can occur in personalities which had previously been quite "normal."    Pinker does point out the likelihood that psychopathic personality--a pathological lack of sympathy for others-- is a risk factor for sadistic behaviour, and that those with this type of personality are more likely to be attracted to occupations in which they could indulge their violent predilections. In the book, he does not address the environmental or social causes of psychopathy, though alludes to this problem being at least to some degree a neurobiological variant with heritable aspects, and not entirely due to environmental adversity. In any case, not all psychopaths end up becoming violent sadists, and not all sadists are psychopaths.

In depressive states, various forms of physical and figurative self-injury can become sources of relief, and lead to an escalating pattern of violence against self.   This is not "sadism" but it could be considered as arising similarly, as an addictive habit to which the person becomes tolerant and desensitized, leading to a craving for more and more highly destructive behaviour.

A solution to this issue is to focus on prevention, and to recognize and avoid risk factors. In a police or military setting, for example, it needs to be recognized that maltreatment of hostile prisoners can occur and escalate through this process. Abuses of this kind are not some kind of bizarre perversion, but stem from failure to include judicial safeguards adequately to prevent the police or prison guards from getting involved in an addictive habit of maltreating others. This can be challenging, because many of the prisoners may have behaved in a terrible way themselves (e.g. violent criminals) and so the initial aggressive responses to them may be approved by everyone involved.

In a personal setting, prevention is also important. Self-injury often begins secretively, without the addictive risks being appreciated, and by the time the problem surfaces to others, it has become an entrenched habit. At this stage, approaching it as a potentially lifelong addictive risk becomes necessary, with a variety of psychotherapeutic strategies employed. For those who engage in sadistic behaviour towards others, I think society should be equipped to approach them as permanent risks to others' safety.   This does not necessarily mean longer prison terms, etc. (though this may be necessary in some instances) but I think it does at least mean longer-term societal scrutiny for protection of others.

6)
Isolation is a risk factor for violence due to a tendency to form a stronger ingroup, view outsiders as a threat, lack the communication or language to resolve disputes peacefully with outsiders, and to lack the advanced education that could bolster diplomacy, empathy, or self-control.

During early human history, groups existed in relative isolation from each other. Today, groups which are more geographically isolated (e.g. in remote mountainous areas) tend to have much higher rates of violence, as well as less education. With the advent of modern communication and transportation technology, isolation on this level does not ever have to be as absolute as it has been in the past. Yet, some groups may deliberately foster isolation, even when they live in large cities. I think it is important to foster widespread community interactions between isolated groups.

On a personal level, isolation is likely to magnify suspicion towards strangers, leading to exaggerated negative reactions to others' behaviour.

Psychologically, problems with isolation may be due to social anxiety, depression, or psychotic paraoia, but the isolation itself becomes part of the vicious cycle of symptom exacerbation.

Every person or community may have a certain "set point" for healthy engagement with others, e.g. some people are more comfortably gregarious than others, but I think some type of social practice and engagement is necessary for the health of individuals and communities.

On a practical level, learning to speak other languages and customs lessens the isolative boundaries between people. As a strategy of personal development, it could therefore be healthy to learn other languages, to travel to different countries, and to experience and learn respectfully about other cultures. Treatment of underlying symptoms, such as paranoia or social phobia, can of course be important.

7)
Authoritarianism evolves naturally from the most ancient origins: stronger members of a group will dominate and assume leadership powers. This factor fits closely with the ideological dynamics of aggression. Those who challenge the authoritarian leadership can be subject to severe aggression. One of the perpetuating factors for this dynamic includes the cognitive illusion that everyone supports the authoritarian leader or the authoritarian principles. Even those who quietly dissent may be so fearful of reprisal that they will act to support the leader, and even punish other dissenters to prove it. An analogous cognitive distortion is the belief among college students that the majority of their peers enjoy binge drinking--this belief normalizes such behaviour, and causes more people to engage in it because they erroneously thought it was an accepted norm.

A protection against this dynamic is fostering a politically open democracy with freedom of speech. On a personal level, I think it is healthy and protective to question authority as an intellectual norm. This includes not only teachers and professors, but also religious teachings. Authoritarianism that is couched in religious dogma can seem so "sacred" that challenging it would seem disrespectful or like a taboo, thus leading to terrible unchecked excesses and distortions justifying violence or other harms and suppressing intellectual growth.

I had assumed that there would be a universal affirmation of the desirability of multi-party democracy throughout the world. Yet, I have recently been looking at the PewResearch Global Attitudes Project surveys, including a poll done in 2009 (well before the recent conflicts in Russia and Ukraine). (link)

This survey shows that people in Russia and several former Eastern-Bloc countries such as Hungary, have had a huge reduction in their enchantment with the idea of democratic government, beginning long before the recent conflicts. Ukrainians gave some of the lowest ratings of all, regarding attitudes towards democracy, freedom of speech, etc.    I suspect that a major reason for this has been that the democratic changes in these countries have been laden with a lot of corruption, instability, and economic problems.

This is reminiscent of what Pinker described in post-colonial African states, which experienced a large surge in violence rates after declaring independence. This does not at all mean that colonialism was "good," but rather that the benefits of democracy and societal freedom can only come after a state has become stable in terms of economy and political organization.   The period after major political upheavals can be relatively anarchic, and economically harsh, leading to a steep decline in morale for the population.

8)
Ideology can lead to extreme violence, through offering a cohesive set of beliefs which bind an ingroup harmoniously, often with a utopian goal, leading to a rationalization to destroy outgroups. Utopian goals can sound attractive, but often the enactment of these goals involve suspension of the other elements of societal growth and non-violence, such as fairness, justice, empathy for outgroup memebers, etc. Those who commit catastrophic acts of violence within an ideological framework may understand their actions to be normal or just, and may easily dismiss complaints that their actions are wrong. Our recent history is full of examples of this type, including Nazi Germany.

Unfortunately, there are many examples in history of religious ideologies leading to extreme violence in this way, continuing with examples in today's news.

A prevention for this type of problem includes education, including in the arts and humanities, a commitment to ecumenical approaches in theology (regardless of one's religious orientation), and a commitment to have diplomatic relationships with those having different ideological viewpoints.

I think these preventions apply on a large scale in societies, but also on a personal, individual level.

9)
Intelligence, the greatest talent of humankind, has the power to defuse conflict through negotiation, wise strategizing, and improved empathic understanding of one's opponents.    Cognitive biases are not eliminated by intelligence alone (as Kahneman has shown), but the capacity to employ reason rather than rage to solve problems is enhanced by intellectual training. Such intelligence has grown over the generations, as Pinker has shown. This is likely due to better education, and exposure to a more stimulating global cultural milieu. Unfortunately, many in the world lack access to the basic resources or freedoms to develop their intellect in this way. Part of global peacemaking must therefore include a strong emphasis on universal access to education.

Intelligence, of course, also permits a higher chance for employment, prosperity, and diverse leisure activities, all of which reduce risks for violence and other harms.

On a more immediate, personal level, intellectual development could be framed as a component of psychotherapy. This could work not only as a way to focus the brain on activities apart from depressive rumination, but also could strengthen faculties of the mind which could act as skilled "negotiators" to calm the self-injurious impulses which can occur in depression or anxiety. Some of the CBT literature shows that this type of therapy works better in those who are more highly educated. Conversely, I suspect that better education and intellectual training can make psychotherapy work better.

Sunday, September 22, 2024

Narcissistic & Antisocial Personality in public figures: the role of mental health professionals

The norm in mental health practice has wisely been to stay out of politics for the most part, except when it comes to mental health advocacy.

It would obviously be problematic if individual mental health experts (such as psychiatrists, psychologists, social workers, nurses, etc.) or groups representing professionals (such as specialist associations, editorial boards from journals, etc.) were to endorse or criticize political figures, with a goal to influence elections.

But sometimes there needs to be an exception to this neutral policy.

Mental health professionals have a great deal of experience recognizing and dealing with individuals who have behavioural and relational problems such as narcissistic and antisocial personality. And the most valuable experience mental health professionals bring to this issue is work with patients whose partner, spouse, close friend, parent, boss, or other family member has narcissistic or antisocial traits.

Narcissistic personality traits or disorder include selfishness, self-absorption, boastfulness, need for admiration, arrogance, exploiting others, and lacking empathy. Antisocial traits or disorder include disregard for others, frequent lying, impulsiveness and poor self-control, aggressiveness, lack of remorse, and criminal behaviours. While we should always have an attitude of attempting to help people with these traits, it is first necessary to ensure that people with these problems are not in a position to harm others. It is especially dangerous when a person in authority, such as a parent, boss, or political leader, has moderate or severe traits of this type. In some ways it is comparable to allowing a small child who has behaviour problems access to a piece of dangerous machinery or weapons.

If a patient is in a close relationship with someone having narcissistic or antisocial traits, there can be many reasons why the patient has a hard time escaping the relationship. The relationship may be all they have known for many years. The relationship may initially have been exciting, passionate, and positive, perhaps an escape from some other adversity, before the narcissistic and antisocial problems showed themselves. Other people in the patient's life, including important figures such as family or church leaders, may insist or encourage that they stay. The patient may not recognize or frame the problems in the relationship as abuse, and may instead normalize the behaviours they suffer or which they observe. Others may be trapped in relationships of this type for economic reasons. They may fear leaving, due to concerns not only about risk of violence, but also of social or economic isolation. Others may experience periods of being cared for at times by their narcissistic or antisocial partner, and/or cared for by the social network which supports this relationship, despite the overall toxicity of the situation.

Sometimes people with antisocial personality lie so often to the people around them, that everyone starts to believe the lies are actually truth, through sheer repetition.

These factors are similar to the cognitive biases I have described in other posts -- interpersonal or group affiliations can be so strong that they keep people locked into certain choices or behaviours due to group or "status quo" loyalty, even when the experiences they are having are very harmful to themselves and others. In such entrenched situations, people will selectively attend to data that supports the status quo, and reflexively reject information that encourages change, even if there is a very strong and compelling level of evidence.

At present, there are important choices in global elections coming up, and a shocking proportion of people appear willing to vote for a person whose behaviour is laden with very serious and dangerous problems. Not only are there severe narcissistic traits, shocking mean-spiritedness, and vitriolic, hateful, divisive language evident on an almost daily basis for many years, there are frank antisocial traits including criminal behaviour in multiple domains, as well as other very troubling features including an obvious lack of intellectual skills, fund of knowledge, interpersonal warmth, humour (except for mockery), patience, balanced capacity for judgment, or intellectual curiosity. There is often frank thought form disorder evident during orations. Furthermore, there will be a team of other people supporting or working with this person who share similar traits, behaviours, and attitudes, in an ever more exaggerated way compared to 5-10 years ago.

Other problems in this case include a lack of fundamental cognitive or intellectual skills, a lack of emotional self-regulation, and a lack of principles that might guide wise, effective, or compassionate decision-making. Instead, I suspect that this person's decisions would often be guided by vindictiveness and attempted self-aggrandizement rather than the good of the country or the world. Attachment to policies supported by particular groups, such as church groups, would only be used as a tool to advance himself. Some individuals with narcissistic or antisocial personality can suppress or hide the narcissistic behaviours quite well, and therefore sneak into positions of power before others have a chance to detect the problems. But in this case, there is a frank display of narcissism almost every time the person speaks, and perhaps a lack of insight or care about it. Most disappointing and shocking to me is that there is such a large segment of the population that laps this awful behaviour up, makes excuses for it, minimizes it, or disregards it as unimportant.

It would be quite straightforward to evaluate this person's intellectual capacity. He is a person who boasted about passing a dementia-screening test as though he thought it was a measure of intelligence. A simple high-school level fund of knowledge test would be interesting, even to identify places on a map of the U.S. or of the world (such as "where is Poland?" or "where is Nebraska"), or to say a little bit about the cultures or histories of different U.S. states or cities or different countries in the world. A short quiz about how the economy works, or about even the most basic science (such as "what is gravity" or "what is electricity" or "what is the air made of") would be quite revealing. A standarized situational judgment test, such as the Casper, often a requirement for applicants to professions requiring interaction with people as part of the work, would be really interesting in this case. My prediction about these things is that the person in question would score a shockingly low percentile on all of these things, and if this was publicized he would as usual surely blame this somehow on the testing being unfair or stacked against him or a product of "cheating" etc.

Another frequent egregious and alarming behaviour in this case is something I've described before: projection. A rhetorical tactic almost always is to use extreme language to denounce other people, or accuse them of some horrible thing, lying all the way through, yet very often the very things he is accusing others of are obvious features of his own behaviour, character, and history.

It is especially shocking that certain groups whose personal and group culture is devoted to devout faith, moral purity, law & order, and personal freedom, would double down in their support for this person whose behaviour is in extreme contradiction to these values. In many religious stories or scriptures, a recurring theme has to do with people of faith being misled or enamored by dark forces--there are many stories where the faithful have lost their way, figuratively or literally, but without having insight or the willingness to change until a lot of harm had been done. These texts encourage people to humbly reflect and be willing to refocus themselves on their values. In this case, I think many people including those with strong, honourable moral values and faith, have very much lost their way in their support of a dangerously unfit leader who is poised to do great harm to their country and the world, in service to himself.

Of course, it is true that unless a detailed assessment were to be done, we could not have the confidence to make a formal psychiatric diagnosis. But in the realm of narcissism and antisocial personality, most of the actual evidence for such diagnoses comes from collateral information of the patient's behaviour. In an actual interview, particularly a single individual interview, many people with problems of this type can present themselves in a seemingly normal way (though in this particular case I think there would be many simple ways in an interview to demonstrate some of the problems unequivocally, especially intellectual weaknesses and almost cartoon-like unsuppressed narcissism).

In any case, this situation reminds me of trying to help a patient (i.e. a large segment of the public) who is in a dangerously abusive relationship with a partner, yet who insists on staying and who might get angry or upset at the suggestion that they could or should think about leaving. The "patient" in this case is a group numbering 40% or more of the population in certain areas.

The role of a mental health professional with a "patient" of this type would involve compassionate and empathic exploration of the history, help with treating symptoms of pain or suffering, but also there would need to be movement towards encouraging change or leaving the relationship, warning about the risks of staying, but with a message of hope for a better, happier, more prosperous, more peaceful future after leaving. Here, a motivational interviewing framework would be needed, since simply encouraging or pushing for change could be very counterproductive if the person does not desire this. Other ideas for helping include tactics similar to what is described in David McRaney's book "How Minds Change." (see my post about this book).

One of the most compelling agents of change or healthy persuasion in this case is to emphasize the role of ingroup members who are speaking out. In this case, there are many examples. When an ingroup member speaks out, people are less likely to dismiss the concerns as simply being the product of political opponents.

Another role of mental health professionals could be to discuss the issue of narcissism, antisocial behaviour, and abusive relationships in a public setting, as an educational endeavour to help people recognize and avoid such relationships in the first place, to be informed about how to get out of such a relationship safely, and to be in a position to help others.

I have felt that the mental health community has not spoken out appropriately about the current public figure issue I have been alluding to. I understand the principles behind the reserve, i.e. staying neutral in politics, but this is such an intensely important issue impacting individual and public well-being that something needs to be said about it. Also, professionals, professional organizations, and editorial boards from journals need not spell out specific opinions about a particular case or a particular person, rather they could simply speak out about recognizing narcissism, antisocial behaviour, entrenched attachment to abusive relationships, the extreme dangers to well-being involved with such situations, the psychological factors preventing change, and things we can all do about it, without spelling out any particular individuals.

I wish there could be psychiatric journals for the month of October where the issue would be devoted to a review of the research and current state of knowledge about recognizing and dealing with narcissistic and antisocial personality traits in relationships with loved ones, bosses, or community leaders. In the absence of this, I at least encourage people to explore the issue themselves at a library or online.

Links:

Garth Kroeker: How Minds Change by David McRaney: a book review and discussion

Garth Kroeker: Political polarization, propaganda, conspiracy theories, misinformation, and vaccine hesitancy: a psychiatric approach to understanding and management

Sunday, October 30, 2016

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.

Garth Kroeker