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Dave is a Licensed Clinical Social Worker who specializes in adolescent and adult group, family and individual therapy. Dave has extensive experience in providing direct service and in management of mental health services. He currently works full time at the Hennepin County Medical Center Partial Hospital Program . He has a particular interest in mental health outcomes research, psycho-education and developing the potential of the Internet in facilitating research in mental health.
Dare To Dream
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- September 25, 2008
- 10:52 PM
- 1,798 views
Is There a Place for Emotion in Cognitive Theory?
by David Johnson, MSW, LICSW in Dare To Dream
Aaron Beck, considered the Father of Cognitive Therapy, is an American psychiatrist and a professor emeritus at the Department of Psychiatry at the University of Pennsylvania. He is President of the Beck Institute for Cognitive Therapy and Research that is directed by his daughter, Judith S. Beck, Ph.D.. He is noted for his research in psychotherapy, psychopathology, suicide, and psychometrics, and the Beck Depression Inventory (BDI), one of the most widely used instruments for measuring depression severity. At age 87, the man is still publishing, building on his pioneering work on the cognitive model of depression. In his latest article published in the American Journal of Psychiatry, he recalls his early work:
Caught up with the contagion of the times, I was prompted to start something on my own. I was particularly intrigued by the paradox of depression. This disorder appeared to violate the time-honored canons of human nature: the self-preservation instinct, the maternal instinct, the sexual instinct, and the pleasure principle. All of these normal human yearnings were dulled or reversed. Even vital biological functions like eating or sleeping were attenuated. The leading causal theory of depression at the time was the notion of inverted hostility. This seemed a reasonable, logical explanation if translated into a need to suffer. The need to punish one's self could account for the loss of pleasure, loss of libido, self-criticism, and suicidal wishes and would be triggered by guilt. I was drawn to conducting clinical research in depression because the field was wide open--and besides, I had a testable hypothesis.
I decided at first to make a foray into the "deepest" level: the dreams of depressed patients. I expected to find signs of more hostility in the dream content of depressed patients than nondepressed patients, but they actually showed less hostility. I did observe, however, that the dreams of depressed patients contained the themes of loss, defeat, rejection, and abandonment, and the dreamer was represented as defective or diseased. At first I assumed the idea that the negative themes in the dream content expressed the need to punish one's self (or "masochism"), but I was soon disabused of this notion. When encouraged to express hostility, my patients became more, not less, depressed. Further, in experiments, they reacted positively to success experiences and positive reinforcement when the "masochism" hypothesis predicted the opposite (summarized in Beck).
Some revealing observations helped to provide the basis for the subsequent cognitive model of depression. I noted that the dream content contained the same themes as the patients' conscious cognitions--their negative self-evaluations, expectancies, and memories--but in an exaggerated, more dramatic form. The depressive cognitions contained errors or distortions in the interpretations (or misinterpretations) of experience. What finally clinched the new model (for me) was our research finding that when the patients reappraised and corrected their misinterpretations, their depression started to lift and--in 10 or 12 sessions--would remit.
We owe a lot to Dr. Beck. His cognitive model of depression still dominates how I and most of my colleagues write treatment plans for persons suffering with depression. Our goal is to inspire and teach our clients to change their negative self-evaluations, correct distorted memories, and create an expectation of success. The only problem is depression is not that simple.
Try as they might, many clients are able to recognize what they need to do, understand how their thoughts about themselves and their world need to change, are able to state those changes, and diligently practice them. But when they really need to be able to master their fate, when ruminative thoughts spiral downward into the depths of depression, their efforts quickly collapse and they succumb.
So is the Cognitive Model of Depression wrong? No, I think it's incomplete. There is the biomedical model of depression involving errant neurotransmitter levels treated by various anti-depressants. That discussion is beyond this article's purpose. I'm more interested in what we as therapists can do differently in the counseling office. Of course we need to be sure a severely depressed client is referred for a medication review. But I want to know how we might better facilitate our clients attempts to master their mood. To this end, I will review my recent reading on the subject of emotion and argue to include emotion in a new Cognitive Theory.... Read more »
Beck, Aaron. (2008) The Evolution of the Cognitive Model of Depression it's Neurobiological Correlates. American Journal of Psychiatry, 969-977. DOI: http://ajp.psychiatryonline.org/cgi/content/full/165/8/969
- March 12, 2008
- 11:11 PM
- 1,708 views
The Limits of Reductionism: Misreading the Mind
by David Johnson, MSW, LICSW in Dare To Dream
I've previously complained about research that so often is focused on small parts and pieces so small that they mean very little to the average person, or even the practitioner in the field. Worse yet, few authors seem willing to reach beyond the data and advance theoretical knowledge. It is at the level of theory development that research reaches into application and education. There seems to have been few willing to work on a new grand theory based on the nearly 50 year old previous attempts that integrates the research results since that time. There has been some important new knowledge ... Read more »
Gregg Henriques. (2003) The tree of knowledge system and the theoretical unification of psychology. Review of General Psychology, 7(2), 150-182. DOI: 10.1037/1089-2680.7.2.150
- April 19, 2009
- 08:01 PM
- 1,696 views
Forgiveness Therapy Endorsed by a Skeptic
by David Johnson, MSW, LICSW in Dare To Dream
Since I heard of all the excitement in the therapy literature about forgiveness therapy, I've been a skeptic. I've worked with a lot of people who have experienced unforgivable abuse. Often they are tortured by their feelings of anger, resentment, helplessness, violation, and shame for allowing themselves to be a victim. They also feel guilt about their anger with the perpetrator so much so they feel morally obligated to forgive the perpetrator. When they do, they seem to feel no personal relief from forgiveness except for less anger and guilt and a better relationship with the perpetrator. But they seem no closer to recovery than before.
I work with persons with depression and anxiety, as well as long standing serious problems with relationships (personality disorder) due to growing up in a chaotic environment. So it is conceivable that forgiveness therapy may have been designed for a healthier population. Seeking to try to better understand this dilemma, I attended a great conference recently taught by Mary Hayes Grieco and colleagues on forgiveness therapy. From the conference flyer:
This day-long course is intended to introduce the counseling professional to a model of wholistic psychological health and an effective method for accomplishing forgiveness that is one of the most useful tools for therapy available today.
You will:
review current research linking forgiveness with stress reduction
learn the Psychosynthesis Model of psychological health and wholeness
learn The Eight Steps of forgiving another and the steps of self forgiveness
understand how forgiveness brings healing into a family system
learn how forgiveness brings integration and closure to trauma survivors
develop strategies for applying the eight steps of forgiveness in a clinical practice
The course material reflects the connection between spirituality and emotional healing but the content is inclusive and non-denominational. We will discuss how to incorporate these concepts appropriately in a secular setting.
It was a small class of 17. Mary and her three assistants seemed to thrive in a small group setting. The atmosphere was most comfortable for listening and it allowed Mary to shine with her skill of personal connection. I got a sense of her therapeutic leadership skills, her gentle and humorous style, and her amazing ability to instill hope with her gentle encouragement. Her eyes positively sparkle with warmth, confidence and belief in her method. She succeeds as well as anyone I've seen providing a secular foundation for spirituality even though her foundations are clearly religious.
She defines forgiveness functionally, rather than semantically. To forgive is to release an expectation that is causing one to suffer, to cancel a debt of demands and expectations that one is holding on to, and to dissolve an attachment that blocks one's flow of love and energy. This is not the moralistic obligatory forgiveness that seems to have locked many of my clients in place.
The core of her method follows:
The Eight Steps of Forgiveness of Another
State your will to make a change in attitude
Express your emotions about what happened
Cancel the expectation(s) you are holding in your mind
Shift expectation to positive preference
Acknowledge reality
Re-state your will to move on; open up to getting your needs met in a different way
Release the expectation with words and inner letting go
Open up to the Universe to receive exactly what you need
Sort out the boundaries: give them responsibility for their actions and take yours; visualize your personal space like a sphere of light around you
Send unconditional love to the person
See the good in them or in the situation
See the good
Notice the physical change and take time to gently integrate it.
Other authors have a bit more elaborate definition of forgiveness. Enright and Fitzgibbons (2000, p. 29), in their book Helping Clients Forgive, defines forgiveness as, after validating the person had been unfairly treated, a person chooses to forgive by willfully abandoning resentment (to which they have a right) and endeavor to respond to the wrongdoer based on the moral principal of beneficence (providing aid without thought of reciprocity or restitution), which may include compassion, unconditional worth (because he is human), generosity (in receiving more than what he deserves), and moral love (concern and respect to which the wrongdoer, by nature of the hurtful act or acts, has no right).
They also define what forgiveness is not: pardon, legal mercy, leniency, condoning, excusing, reconciliation, conciliation, justification, forgetting, restitution, forgiveness for self only. It is not the same as incomplete synonyms of letting time heal, abandoning resentment, possessing positive feelings, saying "i forgive you", making a decision to forgive. They also note confusing similar concepts. Forgiveness is not a quick fix for most. Acceptance and moving on doesn't involve how one feels about the offender. Nor is it in any way cloaked revenge.
Clearly, the forgiveness I had in mind is not what is described here. I had in mind the moralistic obligation to "turn the other cheek", something I've never understood. Mary confidently asserts in her brochure:
Recent research on the relationship of forgiveness to health and happiness demonstrates empirically what religions and philosophers have suggested throughout history: that forgiveness is necessary in order to find peace from life's hurts, losses and disappointments. The ability to move on is critical to completing the emotional healing process.
I think at this point I agree with everything but the use of the word "necessary". The literature review in the presentation gives a compelling argument for the value of forgiveness. But I don't believe I've seen a proof that it is necessary. What the method does contain seems to be a bit broader concept of change. Franz Alexander et al. (1946) defined "the corrective emotional experience:
In all forms of etiological psychotherapy, the basic therapeutic principle is the same: to re-expose the patient, under more favorable circumstances, to emotional situations which he could not handle in the past. The patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.
In my clinical experience, there are two major obstacles to the effectiveness of forgiveness. Reed and Enright (2006) describes them well:
Women who have experienced spousal emotional abuse present at least two unique challenges for recovery. First, learned helplessness (Sackett & Saunders, 1999) develops as a pattern of self-blame in response to the criticism and ridicule by the abusive spouse and often remains well beyond the end of the abusive relationship (Dutton & Painter, 1993). "If only I had done this to please him" quickly deteriorates in the ongoing, unpredictable stress of the abusive relationship to "I am trying to prevent this, but nothing is working" and remains in a residual "Maybe I am worthless and none of my decisions are valid." Therefore, any treatment for these women should demonstrate outcomes in practical decision making and moral decision making....
Second, Seagull and Seagull (1991) described an obstacle to recovery for emotionally abused women labeled accusatory suffering, which entails maintaining resentment and victim status. The assumption in accusatory suffering is that healing the wounds of the abuse will somehow let the perpetrator off the hook. At a deeper level, accusatory suffering may be seen as a defense against the fear that the woman is somehow responsible for her own victimization, a fear that is often inculcated by the victimizer (Sackett & Saunders, 1999). Seagull and Seagull (1991) argued that although accusatory suffering (resentment and victim status) may function as a temporary strategy to help the woman adapt to the extreme experience of spousal emotional abuse, it seriously hinders substantial post-relationship, post-crisis recovery. Therefore, any treatment for these women should demonstrate a change in victim status.
Each of these two obstacles represent major challenges to clients from highly traumatic and abusive environments. The risk of attempting forgiveness prematurely potentially could lock in place both a sense of helplessness and personal responsibility. In that case, forgiveness removes the resentment and improves the broken relationship, it leaves in place the client's vulnerability to recurrence. Reed and Enright (2006) continues:
The FT client is encouraged to tell her own unique story of the abuse experience, with the purpose of working through this story to a healthy resolution that includes forgiveness. During the forgiveness process, the client does the hard work of uncovering anger and shame, grieving the undeserved pain from the abuse, and reframing the former partner (personal history, fallibility, and culpability, yet inherent human worth), with the purpose of relinquishing debilitating resentment.
Key here is the clients' ability to uncover and own their anger and, in particular, the underlying shame. The anger and resentment serves to both motivate the client to face their fears and change their circumstances, while protecting their sense of self from their underlying feeling of responsibility for having allowed the abuse and their own aggressive impulses to avenge their mistreatment. If the resentment is released prematurely, before the shame has been recognized and resolved, the client may be left will little emotional energy to move beyond self-loathing. From Greenberg and Pascual-Leone (2006):
maladaptive shame can be transformed into self-acceptance by accessing anger at violation, self-soothing, compassion, and pride. Thus, the action tendency to shrink into the ground in shame or to flee in fear is transformed by the tendency to thrust forward as part of newly accessed anger at violation or pride at accomplishment. This sequentially ordered pattern is what actually creates confidence.
Thus the negative emotion actually combines with natural positive emotions to trigger a transformation.
Consider this clinical description of a woman with possible borderline personality from Bridges (2006) who failed to respond with an emotional transformation.
Her general tone is one of blame, complaint, and resentment toward her husband for being away and enjoying himself while she is left to deal with the dog's illness. Yet, at no point does she mention that she is angry or even irritated. Her inability to put her anger into words and its relationship to her later waking with a "pain in the neck" almost cries out for interpretation. When she does mention her feelings, it is in regard to the puzzling, perhaps existential statement of feeling "nervous about living a lie." When the therapist makes an explicit attempt to inquire about her feelings related to the recent incident when she had started crying, she responds not by referring to her emotions but by instead focusing on legal details. The overall impression is one of the patient's skipping over the surface of her emotional life via her pressured, externally focused speech as a stone skips over the surface of water.
To summarize, this patient with a "venting" style displayed a pattern characterized by (1) high initial heart rate (HR) with little variability that gradually decreased from beginning to end of session; (2) rapid, incessant speech involving low-intensity expression of negative emotions, primarily complaint, resentment, and externalized blame of others; (3) very low levels of emotional processing (e.g., EXP < 2) characterized by an external focus on frustrating others and events with few references to their personal relevance or meaning or her immediate in-session experience; and (4) self-reports of experiencing intense negative emotions during sessions that were incongruent with her observable emotional behavior. One of the most surprising and interesting findings was that, on a purely physiological level, venting works! This patient showed an average decrease in heart rate from the beginning to end of each session of at least 18 beats per minute (bpm) for 9 of 12 sessions. If one were using progressive relaxation or desensitization and focusing only on decreased arousal as a measure, treatment would appear to be going very well indeed. Although this is obviously not the case, at least for this patient the opportunity to go to a session each week and "get out feelings" while experiencing a very real sense of physiological relief appeared to be very reinforcing in the short term but resulted in little if any long-term change.
So it's not as simple as venting one's anger about mistreatment, but venting reinforces the self-righteous anger by providing temporary emotional relief. To make a long lasting change, it is necessary to ferret out all underlying feelings as well. Resentment often defensively covers shame. The positive aspects of anger can be a strong motivator to transform shame into behavior change. Until this emotional transformation is complete, forgiveness is premature. It's most important to note, that adaptive negative emotions are at the core of movement in transformational therapy. Here anger serves as the energy to transform the shame into pride and confidence. The "debilitating resentment" Reed and Enright (2006) speaks of is not the core of being stuck. It's the shame of an often irrational sense of personal responsibility for ones own trauma and about aggressive impulses for revenge that is covered by the resentment and prevents recovery. Thus forgiveness of the other is not the primary ingredient, but forgiveness of one's self comes first.
Is forgiveness of the offender necessary? That I think depends more on the value system of the client. I believe an emotional transformation from maladaptive anger and shame to angry determination to make changes through self-encouragement and self-nurturance is the primary driver of recovery from trauma. Many of my clients seem to readily make the transformation from resentment to angry determination. Forgiveness, if it comes at all, comes as a consequence of the primary change, effortlessly, later on, as if part of a unforced natural process. Others feel an obligation to forgive and do so as a part of recovery. Unfortunately, too many go through a forgiveness process before they have made an emotional transformation. I find myself trying to encourage them to back track to their anger, which they thought they got over, so they can finally forgive themselves.
To be sure I'm pleased to have another important tool in the therapeutic tool box. However, given the acutity of the population I work with in a short term intensive program, there is probably little utility for full blown group forgiveness therapy. But at the very least I will be much more comfortable with a clients request that they wish to learn to forgive their victimizer.
References
Alexander, F. et al. (1946). Psychoanalytic Therapy: Principles and Application. New York: Ronald Press. Retrieved April 19, 2009, from http://www.psychomedia.it/pm/modther/probpsiter/alexan-2.htm.
Bridges, M. (2006). Activating the corrective emotional experience Journal of Clinical Psychology, 62 (5), 551-568 DOI: 10.1002/jclp.20248
Enright, Robert D. and Fitzgibbons, Richard P. (2000). Helping Clients Forgive - An Empirical Guide for Resolving Anger and Restoring Hope Washington DC: American Psychological Association IBSN: 1-55798-689-4
Greenberg, L., & Pascual-Leone, A. (2006). Emotion in psychotherapy: A practice-friendly research review Journal of Clinical Psychology, 62 (5), 611-630 DOI: 10.1002/jclp.20252
Reed, G., & Enright, R. (2006). The effects of forgiveness therapy on depression, anxiety, and posttraumatic stress for women after spousal emotional abuse. Journal of Consulting and Clinical Psychology, 74 (5), 920-929 DOI: 10.1037/0022-006X.74.5.920... Read more »
Bridges, M. (2006) Activating the corrective emotional experience. Journal of Clinical Psychology, 62(5), 551-568. DOI: 10.1002/jclp.20248
Robert D. Enright, & Richard P. Fitzgibbons. (2000) Helping Clients Forgive - An Empirical Guide for Resolving Anger and Restoring Hope. Washington DC. DOI: 1-55798-689-4
Greenberg, L., & Pascual-Leone, A. (2006) Emotion in psychotherapy: A practice-friendly research review. Journal of Clinical Psychology, 62(5), 611-630. DOI: 10.1002/jclp.20252
Reed, G., & Enright, R. (2006) The effects of forgiveness therapy on depression, anxiety, and posttraumatic stress for women after spousal emotional abuse. Journal of Consulting and Clinical Psychology, 74(5), 920-929. DOI: 10.1037/0022-006X.74.5.920
- March 12, 2008
- 10:16 PM
- 1,668 views
Science and Mass Media Don't Mix Well
by David Johnson, MSW, LICSW in Dare To Dream
Sunday I found a disturbing article in a blog that has a good reputation. Dr. Peter Breggin at The Huffington Post wrote about the FDA decision to require a "black box" warning on the anti-depressant medication Paxil because of the risk of suicide in the beginning of treatment. Dr. Breggin is the author of the book Talking Back to Prozac which is highly critical of the anti-depressant medication Prozac. In his post at Huffington's, Dr. Breggin makes statements that appeared designed to attract attention at the expense of misleading the reader. I've written about the problem with r... Read more »
Irving Kirsch, Thomas Moore, Alan Scorboria, & Sarah Nicholls. (2002) The emperor\'s new drugs: An analysis of antidepressant medication data submitted to the U.S. Food and Drug Administration. . Prevention , 5(1).
- March 12, 2008
- 10:15 PM
- 1,471 views
Paranoia Is A Widespread Problem?
by David Johnson, MSW, LICSW in Dare To Dream
Recently, a post at Anxiety and Depression Treatments Blog got my attention. It refers to a BBC NEWS article titled "Paranoia 'a widespread problem". The article is about a survey done in the UK by the Institute of Psychiatry at King's College London. The blog characterized the results as laughably high. Here is an excerpt from the BBC article.
One in three people in the UK regularly suffers paranoid or suspicious fears, clinical psychologists have found. A team at the Institute of Psychiatry at King's College London interviewed 1,200 people about whether they had thoughts about others... Read more »
D Freeman, P Garety, P Bebbington, B Smith, R Rollinson, D Fowler, E Kuipers, K Ray, & G Dunn. (2005) Psychological investigation of the structure of paranoia in a non-clinical population Freeman D, Garety PA, Bebbington PE, Smith B, Rollinson R, Fowler D, Kuipers E, Ray K, Dunn G. British Journal of Psychiatry, 186(5), 427-435. info:PMID/15863749
- March 12, 2008
- 10:14 PM
- 1,320 views
Secret Shame Contributes to Chronic Depression
by David Johnson, MSW, LICSW in Dare To Dream
Shame has been a particular interest for me. It has appeared repeatedly as a major barrier in therapy, especially in those for whom therapy has failed in the past. It takes a lot of courage to re-enter therapy after feeling it was previously insufficient. Fortunately, a person returning to therapy after a less than satisfactory experience is significant motivated to try new ideas.
Agreeing to therapy is a humbling experience in and of itself. The American culture so values individualism, asking for help is often viewed as a sign of weakness, perhaps more likely by those who need hel... Read more »
Anne Hook, & Bernice Andrews. (2005) The relationship of non-disclosure in therapy to shame and depression. British Journal of Clinical Psychology, 44(3), 425-438. DOI: 10.1348/014466505X34165
- March 12, 2008
- 10:14 PM
- 1,286 views
The Process of Grieving
by David Johnson, MSW, LICSW in Dare To Dream
The Journal of the American Medical Association [February 21, 2007—Vol 297, No. 7] published an important article on grief, Maciejewski et al (2007). While it's hardly definitive research, it represents an exciting trend in research that I've seen in recent years. Researchers seem more willing to take some risks with the rigor of their research models to produce information that is immediately relevant to practice. While, we are a long way from having clear guidance towards an evidenced-based practice in psychotherapy, testing models in active use in the field provides immediately useful... Read more »
Paul Maciejewski, Baohui Zhang, Block D Susan, & Prigerson G Holly. (2007) An Empirical Examination of the Stage Theory of Grief K. , PhD; , MS; D. , MD; G. , PhD. The Journal of the American Medical Association, 297(7), 716-723. http://jama.ama-assn.org/cgi/content/abstract/297/7/716
- January 19, 2011
- 09:51 PM
- 1,045 views
Book Review: When the Past is Always Present; A New PTSD Treatment?
by David Johnson, MSW, LICSW in Dare To Dream
by Ronald Ruden, MD, PhD
When the Past Is Always Present: Emotional Traumatization, Causes, and Cures introduces a new treatment for trauma. Ronald A. Ruden is an internal medicine physician practicing in Manhattan. Since beginning his practice in 1983, he has dedicated part of the proceeds to follow research interests. His first efforts resulted in the book, The Craving Brain, a neurobiological discussion of addictive behaviors. In 2003 he redirected his interest in understanding traumatization. That has led to three publications in Traumatology, edited by Charles Figley, and to this book.
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The book begins with an easy to understand review of the neurobiological and neuropsychological literature as it relates to trauma. His intent is to provide a primer that a lay person could understand. He still provides adequate citations for those who have deeper interests.
Ruden believes that the means to treat Post Traumatic Stress Disorder (PTSD) is to use the senses. This idea, which is at the core of the theory of psychosensory therapy, forms what the author considers the "third pillar" of trauma treatment. The first and second pillars refer to psychotherapy and psychopharmacology. The theory of psychosensory therapy postulates that sensory input, for example, touch "creates extrasensory activity that alters brain function and the way we respond to stimuli". In other words, new sensory input can change memories and their power over us.
"...the human brain can change it's own structure and function with thought and experience, turning on its own genes to change its circuitry, reorganize itself and change its operation, is the most important alteration in our understanding of the brain in 400 years." (Norman Doidge, MD pXVII in Ruden, 2011)
This process of brain modification is called neuro-platisticity. Evidence of this concept has begun a revolution in thinking about the brain. No longer can one assume that brain damage creates an impermeable barrier to recovery. The point is we can change how well our brain functions if we work at it. If we neglect our brain, it will deteriorate before it's time. Yoga, mindfulness, meditation, and exercise enhance resilience. Resilience is associated with high self-esteem, good emotion regulation skills, optimism, healthy relationships, and an active problem solving response. When you believing you can meet your needs, you feel self-contained, like your world can be managed, you can respond to challenges and can readily find help if you need it. Vulnerability is increased by putting aside your needs to care for others, low self-esteem, difficulty in regulating the intensity and duration of emotions, obsessive-compulsive traits, introversion or being very shy, being anxiety prone, substance abuse, poverty and low education.
"In early life, when the limbic system has not completely formed (the hippocampus is not yet functional), highly emotional moments that occur become stored in a separate memory system called procedural [or implicit] memory.... The cognitive component of the event is not stored...." (Ruden, 2011, p24) When a child experiences trauma, the emotional memory is stored in a part of the brain not easily accessed by our thoughts, our conscious mind. But the memory is there ready to be triggered some event that reminds you of the traumatic memory. You may not even understand why you feel the intense emotions which will add to your confusion and anguish. Chronic release of stress chemicals by repeated triggered panic, changes the landscape of the brain producing self-defeating behavior and thinking, stress related disease, and vulnerability to further traumatization. Retraumatization may be related to repetition compulsion, a homeostatic driven need to heal. If you seek mastery over a situation without new skills to ensure success, the memory is triggered without the healing sense of safe haven, increasing the compulsion to seek mastery. Subconsciously, you may reenact the trauma by repeatedly exposing yourself to a similar trauma.
The second idea presented in this book is that traumatization is encoded into the implicit memory only under special circumstances. Traumatic memories are formed by an emotion-producing event with significant meaning to the individual, the brain must be appropriately primed to acute stress, and the event must be perceived as inescapable. (Ruden, 2011, p47) Encoding is completed at high norepinepherine and dopamine levels, while the prefrontal cortex is shut down. (Ruden, 2011, p59) Ruden insists the trauma must be perceived as inescapable for encoding as a traumatic memory. Feeling trapped, unable to escape takes the prefrontal cortex is taken off line, and we are unable to plan or think. (Ruden, 2011, p47-49) In my clinical experience, feeling trapped, responsible, and in some part to blame for the outcome also appears to play an important role in the development of PTSD.
"The third idea is that traumatization occurs because we cannot find a haven during the event. This is the cornerstone of havening, the particular form of psychosensory therapy described in the book. Using evolutionary biological principles and recently published neuroscientific studies, this book outlines in detail how havening touch de-links the emotional experience from a trauma, essentially making it just an ordinary memory. Once done, the event no longer causes distress." (Yaffe & Ruden Medical Associates)
Ruden's proposed treatment provides another method to unlearn these emotional reactions and retrieve a sense of mastery and safety after a traumatizing experience. Ruden's approach and other sensory-based techniques, are exposure based, a method that has extensive research support. Ruden's claims that animal research supports the notion that bilateral stimulation enhances healing is at best weakly supported by the studies cited.
Rasolkhani-Kalhorn & Harper (2006) appears to be Ruden's primary reference. The authors of this article acknowledge the limitations of the research support for their theory. They use anecdotal research evidence from animal studies to suggest that Eye-movement Desensitization and Reprocessing therapy (EMDR) and other psychosensory therapies, work by stimulating part of the brain to decouple the emotion from the memory. Those studies use fMRI, a scanning technique that can detect brain activity, and other methods. The idea is where there is brain activity when a person is doing something, identifies what parts of the brain are involved. However, every scan shows a lot of activity that is not understood and only some that is thought to be related. The method doesn't prove causation, only a relationship of co-occurance in time or correlation. There is no direct evidence that this correlation in animal brains will translate to human brains. There are real structural differences between humans and animals. So the research results at best only suggest that bilateral stimulation might be related to decoupling emotion from memories.
Ruden's theory is a bit different. When a traumatic event is recalled or reenacted while the survivor is in safe haven, the trauma-induced linkages are disrupted and the emotional response is subsides or is eliminated. According to Behavior Theory, a well research and widely accepted model, a conditioned emotional response is said to "extinguish" when it is repeatedly stimulated when the person feels safe. But Ruden's theory goes much fu... Read more »
Rasolkhani-Kalhorn, T., & Harper, M. (2006) EMDR and Low Frequency Stimulation of the Brain. Traumatology, 12(1), 9-24. DOI: 10.1177/153476560601200102
Ruden, R. (2011) When the Past is Always Present. Psychosocial Stress Series. Routledge. info:other/978-0-415-87564-6
- December 28, 2008
- 01:27 PM
- 935 views
Clients, Not Practitioners, Make Therapy Work
by David Johnson, MSW, LICSW in Dare To Dream
Image via Wikipedia
I have been really enjoying my access to a large number of professional journals over the past couple years. Working at a teaching hospital definitely has it's academic perks. I've been particularly gratified to see a growing sophistication in research methods, creative approaches and a maturing view of results.
Until recently, practice based research articles have often taken the form of providing some support for a therapist preferred approach to therapy. I can understand that, for I am too, highly invested in how I do and why I do it. But many if not most therapy based research describes a new fangled therapy with a new name. This sort of research seems to me to be more self-serving and contributing to a ever fracturing of psychological science. There are so many theories and therapy methods with rather limited clear definitions or research support, there is little opportunity for advancing knowledge of what works.
A new book was announced at the Annual Conference of the British Association For Counselling & Psychotherapy. Titled Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly, it is written by Professor Mick Cooper of the University of Strathclyde. The book is a research review focused on common factors successful therapy. "The book, which is the first reader-friendly summary of research findings in the field, also offers advice to people who are considering seeing a therapist, on their choice of practitioner and the best type of therapy available to them." The author concludes that the most important factor is a client who is motivated and actively involved in using therapy to build on his or her strengths. In addition, one of the best indicators of a positive therapeutic outcome is a strong relationship between therapist and client. These two factors are far more important than a therapist's ideology or particular techniques.
This is not news to those inside the field who have been paying attention. When I was in training in the late 70's, warmth, empathy, genuineness and humor were thought of as important therapist attibutes because they contributed to a good working relationship with the client. Then it was widely understood that psychologically minded persons, capable of abstraction, insight, self-reflection, and most importantly, with motivation to follow through on treatment outside of the session were found to be ideal candidates for therapy. Unfortunately, they were those least likely to need therapy!
Research took an ideological turn when Cognitive Behavior Therapy became the most thoroughly researched treatment method. And early claims were that results were consistently better than what they called "placebo". Now it seems, advocates, academia, even insurance companies are on the CBT bandwagon, tauting this one method as the only way to go. Even the British government has invested committed £170 million over three years to expanding the availability of CBT.
The trouble is that 20 years of research had complied an impressively large pile of research papers that document a very little differences in improvement when comparing CBT, every kind of manual defined treatment modality known to man. The author of the book argues:
Many clients will benefit from CBT but there is a danger in putting too much emphasis on the type of therapy that a therapist provides, rather than the therapist's ability to relate to his or her client in caring and understanding ways, and the needs and preferences of individual clients. Rather than moving towards a therapeutic 'monoculture', we need to be able to provide people with a range of therapies and therapists, so that they can choose the one that best suits them and build on their particular strengths.
[..]Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. Ask yourself whether you like your therapist and feel respected by them - the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process.
What a breath of fresh air!
Reading this book review reminded me of a number of articles I read a couple years ago linked to The Institute for the Study of Therapeutic Change (ISTC) founded by Scott Miller, Barry Duncan, and Mark Hubble. Their collaboration "resulted in several books and dozens of articles, and culminated in the APA best selling, The Heart and Soul of Change. As detailed in that book, the things that make therapy work are largely about the client--the true hero of therapeutic change--and the quality of the relationship formed with the therapist, far more important than model or technique."
Michael J. Lambert of Brigham Young University in 2005 published an article in the Journal of Clinical Psychology on common factors in effective psychotherapy. Lambert takes his argument down a creative path. He suggests that the attention placebo includes therapeutic effective common factors.
Placebo is a research concept that is most commonly used in pharmacological research. Basically, if you find a drug that most people find better than a sugar pill, you have a new product! There is a problem when you apply this concept to researching outcomes in psychotherapy. Just what is the therapy version of a sugar pill? A placebo for therapy outcome has been said to include life events, social support, hopeful expectations, and biochemical changes that accompany treatment and enhance immune function and biochemical balances that facilitate recovery. The problem is therapy is all about providing social support and hopeful expectations from the effectiveness of the therapeutic relationship, the so called "attention placebo."
The "social support, hopeful expectations" part of therapy are essentially the "attention" part of the placebo effect. Certainly this part of a placebo effect is an essential part of psychotherapy, not something to be merely separated or controlled from measurement of therapeutic effectiveness. Lambert effectively makes that point:
Placebo controls make less sense when extended to psychotherapy research because the benefits of treatments and placebos depend on psychological mechanisms. Many authors in the 1980s rejected the placebo concept in psychotherapy research because it is not conceptually consistent with testing the efficacy of psychological procedures (e.g., Dush, 1986; Horvath, 1988; Wilkins, 1984). Nevertheless, the search for causes of improved patient functioning within the traditional scientific method has persisted, albeit under a variety of different terms. Rosenthal and Frank (1956) defined a placebo as being theoretically inert. It is inert, however, only from the standpoint of the theory behind the therapy studied. As Critelli and Neumann (1984) have observed, "virtually every currently established psychotherapy would be considered inert, and therefore a placebo, from the viewpoint of other established theories of cure" (p. 33). Consequently, placebos have sometimes been labeled as nonspecific factors (e.g., Oei & Shuttlewood, 1996). This conceptualization raises serious questions about the definition of nonspecific. Once a nonspecific factor is labeled, does it then become a specific factor and fall outside the domain of a placebo effect? For example, if a variable like therapist warmth is operationally defined and measured does it then become a specific factor, but if not measured a nonspecific (i.e., placebo)? (Bowers & Clum, 1988). Others have suggested the term common factors as a replacement for terms like placebo and nonspecific, in recognition that many therapies have ingredients that are not unique but are nonetheless efficacious. Thus, research on placebo effects might be better conceptualized as research on common factors versus the specific effects of a particular and unique technique.
Common factors are those dimensions of the treatment setting (therapist, therapy, client) that are not specific to any particular technique. Research on the broader concept of common factors investigates causal mechanisms such as expectation for improvement, therapist confidence, and a therapeutic relationship that is characterized by trust, warmth, understanding, acceptance, kindness, and human wisdom. But also can be expanded to include some mechanisms that are often regarded as unique to a particular form of treatment such as exposure to anxiety-provoking stimuli, encouragement to participate in other risk-taking behavior (facing rather than avoiding situations that make the patient uncomfortable), and encouraging client efforts at mastery such as practicing and rehearsing behaviors. Such a view of common factors recognizes that while specific theories of psychotherapy may emphasize systematic in vivo or in vitro exposure to frightening situations, or social skills training, nearly all therapies encourage people to review and discuss the things they fear and face rather than avoid such situations. Common factors, no matter how unimportant they may be from the point of view of a particular theory (theoretically inert or trivial) are central to nearly all psychological interventions in practice, if not, theory.
Lambert's review finds one factor is consistently found to be an important key to therapeutic effectiveness, the relationship between the therapist and the client. Most notably, outcome may be largely related to early response to treatment, before the core techniques have been implemented by the therapist.
At present, the active mechanism linking early response to long-term outcomes is unknown. Whatever the active ingredients are, they appear to work quickly in many cases. The timing of improvements during psychotherapy has theoretical implications beyond placebo explanations for change. If response to therapy precedes introduction of theoretically important techniques, then it is difficult to attribute central importance to these techniques in the healing process. Early responders to psychotherapy may be more resilient, better prepared, more motivated, and thus more receptive to therapeutic influences of any kind. Early response may also indicate a better fit between client and therapist and reflect the positive effects of the working alliance which often can be detected by the third session of treatment. For example, Krupnick et al. (2000) found that the relationship between the client and his or her therapist was most predictive of outcome. This finding is notable because the authors encountered this result across treatment modalities, including two distinct psychotherapies, as well as antidepressant medication, and placebo conditions.
This and a number of other research reviews make a persuasive argument that therapeutic technique is relatively unimportant in maximizing a positive outcome. CBT has been found to be minimally more effective than other therapy approaches. I could imagine how manualized treatment that is most common in these research studies may well minimize the early response factors Lambert mentions above. CBT, designed for a manualized approach, may be less susceptible to suppressing early responses and thus has a more consistent record of comparatively more positive outcomes. Since the magnitude of response when comparing outcomes across therapeutic techniques are minimal in most cases, it seems particularly unwise to attribute CBT with the best outcomes, especially since the most important factors related to therapeutic outcomes have been systematically controlled out or inadvertently suppressed by the manualized approach.
References:
Michael J. Lambert (2005). Early response in psychotherapy: Further evidence for the importance of common factors rather than "placebo effects" Journal of Clinical Psychology, 61 (7), 855-869 DOI: 10.1002/jclp.20130
Miller, S., & Duncan, B. (n.d.). "What Works" in Therapy? TalkingCure.com. Retrieved December 28, 2008, from http://www.talkingcure.com/reference.asp?id=100.
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Michael J. Lambert. (2005) Early response in psychotherapy: Further evidence for the importance of common factors rather than “placebo effects”. Journal of Clinical Psychology, 61(7), 855-869. DOI: 10.1002/jclp.20130
- June 29, 2009
- 11:19 PM
- 752 views
Positive Thoughts Make Things Worse for Poor Self-Esteem??
by David Johnson, MSW, LICSW in Dare To Dream
Image via Wikipedia
I caught this article at Psychcentral.com, Positive Thoughts Make Things Worse for Poor Self-Esteem . It struck me as a counter-intuitive finding for a research study. I've been helping clients build self-esteem for over 30 years and while positive thoughts is not a short road to better self-esteem, it certainly does work over the long run. I'd estimate that at least six months is required to make significant progress with self-esteem from solely refocusing on the positive, and some people require much more time. Several things jumped at me as I read the article. First of all, Dr. Grohol quoted an article from the The Economist of all places. Both articles stated the research was published in this month's Psychology Research and authored by Wood et al (2009). A review of the past three months of that journal produced no article.
So I went to the old reliable, I googled the lead author, Joanne Wood. I came up with several mentions of her at academic institutions and emailed the author for a reprint. I also found another review of the same article by Ed Yong writer for the Science Blog Not Exactly Rocket Science dated May 15th.
The next day, the article arrived in my email with a short note from the author saying it hadn't been published yet! Apparently, there have been some pre-publication prints floating about likely for publicity purposes. This is one of my pet peeves. Articles submitted to peer reviewed journals are intended to inform the academic community and allow scholarly review and comment. The object of repeated review is to ensure the research is sound and is appropriately interpreted. When it appears first in lay publications, the writers who are not scientists often inadvertently distort the interpretation of the research, as I've noted before. That really didn't happen this time. Both the Psychcentral.com and The Economist got the research mostly right. But Ed Yong did a much better job of explaining the fine points.
This time, it's the researchers that make a subtle but major error in an assumption involving an interpretation of a key measurement. Its subtle because it's endemic in our culture. It seems like everyone assumes that negative feelings are harmful. In this case, Wood et al (2009) found that their subjects who had low self-esteem, immediately reported a lower mood and self-esteem after telling themselves sixteen times they are a "lovable person." Interestingly, persons with high self-esteem report only slight, non-significant improvement in self-esteem.
I decided to do an anecdotal demonstration of the "intervention" for my own understanding. After saying to my self 16 times "I am a loveable person", I felt annoyed, a little silly, embarrassed, and was reminded of quite a few traits which make me not always so lovable. But I can't imagine how this would have any long term effect on my self-esteem either way.
An even bigger problem is one that I talked about before and called it Dust Bowl Empiricism. Researchers are so enamored with their professional activities, they demonstrate their preference for inductive research. Wood et al. reviewed all the relevant research on their topic quite satisfactorily, but then failed to do a sufficient review of related theory. In previous post, I quoted Michael Schermer, a columnist with Scientific American, who eloquently asserted that the really valuable research, the kind of research that can fairly readily be used to educate the public, "higher-order works of science that synthesize and coalesce primary sources into a unifying whole toward the purpose of testing a general theory or answering a grand question." To be fair, few researchers venture into grand theory, perhaps because of the dearth of recent reviews, and perhaps because of the few notable exceptions have been eviscerated by their colleagues for their efforts. Sigmund Freud comes to mind. I have sometimes wondered if psychology's love-hate relationship with Freud resulted in an over-emphasis on induction and de-emphasis of deduction and construct validity.
Wood et al. appears to be testing a specific intervention using Cognitive Behavior Therapy (CBT). CBT purports to change feelings by changing thoughts.
While I prefer more psychodynamic conceptualizations, lets approach this issue of negative feelings from cognitive-behavioral point of view for purposes of demonstrating how relevent theory would aide in the interpretation of research. There is conceivable explanation of low self-esteem and associated negative emotion in the concept of "conditioned emotional response" or CER. A person may learn they are not valuable or important by, for example, an invalidating experience. That invalidating experience is remembered in at least two ways, by the facts of the event and by the associated emotions. According to current understanding of neurophysiology, memories of facts and emotions are kept in different part of the brain, presumably by different methods of storage with different processes of recall. The hippocampus and medial temporal lobe are involved in verbalized memories. Emotional memories involve the amygdala.
Sufficient invalidating experiences may lead to low self-esteem. Whenever a sufferer of low self-esteem remembers an invalidating experience or experiences a new one, she is likely to remember the event and feel the emotion associated with the experience.
In the Wood et al. experiment, the lowered mood and self-esteem are experienced after a validating experience. The subject feels the emotions associated with the original invalidating experience of invalidation perhaps because the positive self-talk controdicts the perception of the subject. Wood et al. makes that point. However, what she misses is that the subject is under going extinction of the conditioned emotional response. The subject is experiencing the emotion without the triggering invalidating experience. According to the theory of Classical Conditioning, repeated exposures to the emotion without the associated invalidation will eventually weaken the conditioning. Perhaps this process is complicated by the fact that the alternative experience, validation, is a close opposite to the conditioning stimulus, triggering a strong emotional response.
In my experience, this triggering of a strong negative emotional response associated with past destructive learning without the presence of the negative stimulus actually quickens the de-conditioning. What this experience amounts to is an abreaction, an emotional re-experiencing of the past event in a supportive and nurturing environment.
One point of the research is well taken. A person with an abysmal self-esteem reading a self-help book will find herself ruminating about how wrong it is that she could be so lovable. Such a person, supported only by herself, is not receiving the necessary nurturing due to her low self-esteem. She is likely re-conditioning the CER with more invalidating self-talk.
The reviews of this article did a fair job of presenting the study. However, there is risk in presenting research to a lay audience. The well written review by Yong had unintended consequences. The comments below the article contained some anquished and angry responses:
As a person with very low self-esteem who has been encouraged to think positively and love myself throughout my life, I can only thank Joanne Wood for publishing this study. Packaged... Read more »
Wood, J., Elaine Perunovic, W., & Lee, J. (2009) Positive Self-Statements: Power for Some, Peril for Others. Psychological Science. DOI: 10.1111/j.1467-9280.2009.02370.x
- May 20, 2009
- 05:14 PM
- 611 views
How Do You Inspire a Client to Believe in Therapy?
by David Johnson, MSW, LICSW in Dare To Dream
Image via Wikipedia
Recently, I exchanged messages with Michele Rosenthal, author of the blog, Parasites of the Mind. She asked me a very good question, one that is so much a part of my everyday work, a good long contemplation was needed just to tease out a good answer.
Speaking of inspiring, how do you inspire a client to believe in what he/she is doing? It's so difficult to believe in anything when PTSD has settled its big black cloud on your head.
Any general rules of the game for (self) empowering belief?
Another therapist, Mary Redoutey, joined our discussion and attempted to answer this question. She took the conventional route.
All therapy in essence is self empowered therapy.... The therapist is the partner in the process. I can sit in the chair in my office, can make suggestions, can teach, can do anything as much as I want... and nothing different will happen unless of course the client is present, listens somewhat attentively, suspends negativity long enough to experience a shift in feeling state and/or thoughts or actions.... And the work in the session does not transfer into the client's life unless the client chooses to make the necessary changes.
Essentially, Mary says that therapists don't change people, people can only change themselves. I have commented on a release for a new book that made this point as well. While it is true that what a client brings to therapy may account for much of the effectiveness of therapy, I don't think this is the core of Michelle's question. As I understand her question, she wants to know what the therapist brings to the therapy room.
My first attempt at replying was rooted in my daily routine. I'm always helping people understand how their past experience impinges on their current symptoms.
Consider what happens between mother and child. A child develops their self-concept initially based on how they are treated by their mother. In therapy, the therapist communicates his belief in the client. And if the connection already exists, a seed is planted. But as an adult, only the client can nurture the seed to germination and growth. The therapist can only teach them how.
Generally, when I take this tact, which is common with the childhood trauma survivors I see, I am helping them see the importance of exploring their childhood history and their relationships with their caregivers as a way to understand the origins of their symptoms. This is a much more specific answer that still only partly answers Michelle's question.
I think Michelle wants to know what is the therapists role in motivating a client in each and every step through therapy. In other words, what is the client getting from paid expert advice they can't get from a book? From Michelle's point of view, perceptions of her options are clouded by the rollercoaster existence that accompanies PTSD.
There has been extensive research on this topic. Most recently, much of this research has taken on a ideological fervor endorsing Cognitive Behavior Therapy (CBT). I've written often about my opinion CBT. Suffice it to say, CBT may be the core methodology in helping a client manage their thoughts and building treatment plans, but there is much more to behavior change than changing thoughts. One of CBT's central assumptions is patently false. Not all feelings are produced by or changable by thoughts. Much of our earliest learning occurs before thoughts begin to play a major role in our learning around the age of 8.
Patterson (1989) identified common specific factors recognized by virtually all schools of psychotherapy. He included therapist acceptance, permissiveness, warmth, respect, nonjudgmentalism, honesty, genuineness, and empathy or empathic understanding. Three of these, warmth, empathy, and genuineness have considerable research backing. In a previous article, Patterson (1984) points out:
There are few things in the field of psychology for which the evidence is so strong. The evidence for the necessity, if not the sufficiency, of the therapist conditions of accurate empathy, respect, or warmth, and therapeutic genuineness in incontrovertible.... The fact that specific change occurs in a therapeutic relationship without the addition of so-called specific techniques, such as interpretation, suggestion, instruction, etc., is also evidence of the sufficiency of the relationship by itself.
More recent research has found the competence of the therapist is critical. Verhofstadt et al. 2008, in their article about the value of emotional similarity and empathic accuracy in support giving with couples. They cite:
...mounting evidence that unskilled support can be ineffective or even harmful to the support recipient....
In summary, whereas matching the partner's emotion during a support-seeking interaction may provide a sufficient basis for understanding the partner's current affective state(s) and responding with appropriate emotional support and consolation, understanding the partner's specific thoughts and feelings during a support-seeking interaction may provide a sufficient basis for understanding what kind(s) of help the partner desires and how to provide such help in an acceptable way.
Successful therapists must be able to adapt to their clients' emotional uniqueness and to accurately perceive their thoughts and feelings to provide appropriate support in an acceptable way. Perhaps even more important, therapists must be perceptive and adaptive enough to understand the clients complaint that brought them to therapy and the nature of their quandary beyond the clients' own understanding, or the underlying problems. And having discovered what must be done, therapists must be able to provide the clients insight into their dilemma, provide a rationale for a course of action, and persuade their clients to make changes they are unlikely to find easy or achieve without significant discomfort. Initially, clients are often unable to understand the significance of their problems or nature and potential benefit of the required changes. If they did they wouldn't need therapy!
There is only one experience that I find cuts through virtually any dark cloud, and that is the touch of human empathy. When people who are overwhelmed by pain suddenly find someone who seems to understand how they feel, they no longer feel alone and abandoned by the world. A skilled therapist can provide more than the usual kind of empathy. After years of exploring the human condition, the therapist reaches within the client's experience that at least begins to provide some meaning to explain and place in context her experience.
Preston and de Waal (2002) describes the nature of human interaction as involving an exchange of complementary emotional and thought messages. These shared representations allow people to adjust their responses based on the communicated states of others suited to relieve each others' distress. (Cited in Gruhn et al., 2008)
Grillion et al. (2008) describe the emotional exchange between client and therapist and the unique skills required of the therapist.
When the context becomes safe enough for the client to lower his or her defenses, the alteration of regulatory structures becomes possible. The therapist's own self-regulatory movements reveal his or her inner states to the client. Much like the "good enough mother", the therapist's efforts to regulate his or her own inner states show the client that he or she is in contact with the client. Personal therapy for therapists helps to extend the range of experience that they can draw upon in their work with clients (Schore, 2006, cited in Grillion et al. (2008). According to Amini et al. (1996) the most effective interventions are based on the therapist's awareness of his or her own physical, emotional, and ideational responses to the client's veiled messages.
Accordingly, when the therapist has increasingly expanded self-integration and awareness in regard to his or her state of mind with respect... Read more »
Grillon, C., Pine, D., Lissek, S., Rabin, S., & Vythilingam, M. (2009) Increased Anxiety During Anticipation of Unpredictable Aversive Stimuli in Posttraumatic Stress Disorder but not in Generalized Anxiety Disorder. Biological Psychiatry. DOI: 10.1016/j.biopsych.2008.12.028
Grühn, D., Rebucal, K., Diehl, M., Lumley, M., & Labouvie-Vief, G. (2008) Empathy across the adult lifespan: Longitudinal and experience-sampling findings. Emotion, 8(6), 753-765. DOI: 10.1037/a0014123
Patterson, C. H. (1984) Empathy Warmth And Genuiness In Psychotherapy: A Review Of Reviews. Psychotherapy, 431-438.
Patterson, C. H. (1986) Foundations For A Systematic Eclectic Psychotherapy. Psychotherapy, 427-435.
Verhofstadt, L., Buysse, A., Ickes, W., Davis, M., & Devoldre, I. (2008) Support provision in marriage: The role of emotional similarity and empathic accuracy. Emotion, 8(6), 792-802. DOI: 10.1037/a0013976
- March 12, 2010
- 08:30 PM
- 484 views
Self-Knowledge - Emotional Intelligence For Personal Growth Part IV
by David Johnson, MSW, LICSW in Dare To Dream
This is the fourth in a series of articles on emotional intelligence for personal growth.
Self-knowledge is something we all strive towards. But how many of us have done a complete review of our emotions and how they influence our thoughts and behavior? Most people find that pretty hard to do, especially since they struggle to put their feelings into words. We talk about "will power" as the ultimate motivation. It might surprise you to find out that motivation is really emotion.
Emotion in it's simplest form is motivation, "...each emotion offers a distinctive readiness to act; each points us in a direction that has worked well to handle the recurrent challenges of human life." (Goleman, 1995, p4) Entering a state of mindfulness or flow a person reaches "perhaps the ultimate in harnessing the emotions in the service of performance and learning. In flow, the emotions are not just contained and channeled, but positive; energized; and aligned with the task at hand." (Goleman, 1995, p90)
The skill of reading another's feelings is built on self-awareness and flow. People who have good empathy skills are better adjusted emotionally, more popular, more outgoing, and more sensitive. Childhood neglect dulls empathy. Abuse makes people hypervigilent to emotional cues. Empathy predicts intervention to prevent injury to another, certainly an important action in primitive communities.
Expressions of emotions have been found to be a cross-cultural repertoire of non-verbal emotion communication and serve essential functions in cooperative society. "...emotional communication functions to bond social groups. ...language evolved as a more efficient form of grooming and facilitates group cohesion. ...the use of clear signals to communicate intentions and motivations aids the regulation of group processes." (Waller et al 2008)
Human attributes, as important motivation, self-awareness, empathy, non-verbal communication, get little attention in education in our society. The very complexity of our current circumstances makes it our mutual interest to ensure that our community has learned as much as possible about how to understand emotions.
Psychologists have been studying cognitive bias for many years. The various biases demonstrated in these psychological experiments suggest that people will frequently fail to make rational judgments in systematic, directional ways that are predictable. How many of us understand how bias works in our lives?
Many people persistently avoid and suppress negative emotions because of how painful they are. The trouble is, the more they avoid negative emotion, the more negative experiences they have. Those who have experienced emotional excess at it's worst have been traumatized as a result. Revisiting memories of the events seems to stir up the pain all over again for no good reason.
But there is a heavy cost for avoiding emotion. The very act of making a decision and acting on it with any level of motivation depends on emotion. The kind of snap judgments we make in social situations require a finely tuned awareness of our emotional reactions. Even in decisions that allow more time for reasoning, seldom do we have sufficient factual information to make it completely rational. Instead, we have to weigh the information we have with emotional memories of similar situations and intuitions about the current situation to make our best judgment.
People who have learned to numb their emotions have impaired judgment. Their social judgments, their problem-solving and decision making are plagued by systematic error. Many report finding themselves in repeating past mistakes. Many lament that they repeatedly find themselves unsatisfactory relationships, sometimes with abusive and/or chemically dependent partners. They may not recall an error in judgment such as an event they over-looked that might have warned them of the ultimate outcome.
Understanding our emotions is critical to self-knowledge.This is often the part of ourselves we know the least about. However, our ability to read and make use of emotions has been honed over thousands of generations. Even our chimpanzee friends have a similar ability, though no where near as well developed as ours. This conceptual skill is called the "theory of mind." The term theory of mind was introduced into the scientific literature by primatologists who observed a chimpanzee's ability to understand the intentions of an actor in film clips, which enabled her to predict the actor's next move. Theory of mind is the ability to be aware of others' mental states as different from our own. We then use that knowledge to identify others' intentions, motives, beliefs, desires, and feelings in order to interpret their behavior. This is a skill we all have and use all the time. It is critical to communication, building and maintaining relationships, and for most us, our ability to make a living.
A mother, attuned to her child, responded emotionally, physically, and supportively to the child's expressed distress. The mother's theory of her child's mind allows her to anticipate the child's needs and provide for them. Her facilitative movements and empathetic facial expressions communicate her emotional and physical attunement to her child in a way that helps the child convert a felt, physical, sensory experience into a contained mental, conscious awareness of his internal experience, the warm supportive presense of his mother. That awareness enables the child to regulate his affect and distress. It enables the child to develop a sense of self different and separate from his concept of his mother. Mother, then ultimately others, come to be seen as a source of relief, comfort and pleasure. Self-expression comes to be seen as good, loved, accepted, and competent. From this basic begining, the child develops a rudimentary sense of self (Wallin, 2007).
Consciously practiced mindful self-awareness provides an opportunity for the development of a theory of mind for ourselves. Our ability to interpret others behavior utilizes a finely tuned ability to perceive not only a person's behavior, but their unspoken intent. Understanding our own behavior is not so easy. In a real sense, others can see us and interpret our intentions much better than we can. We would rather believe that we know our own minds, that we have a clear idea why we do what we do. Research says that that is often not true. There are all sorts of influences to decision of which we are unaware. Our ability to predict expected punishment is enhanced by our bodily arousal (Dolan, 2002). It would appear that a cool and reasoned state of mind is not as good at predicting punishment. Yet we make some judgments and prepare ourselves for response without any awareness (Kahneman, 2003). Well-learned goals can be activated by environmental stimuli and attendant behavioral plans can run their course without conscious awareness. People can be unknowingly enticed to either trounce an incompetent competitor or protect his self-esteem by words that that encourage acheivement or friendship (Westen, 1998).
Interpreting another's behavior is enhanced by our ability to face and observe that person. We cannot observe ourselves directly. Instead, we rely on our ability to remember our thoughts, feelings and behaviors and make inferences after the fact. There are many unconscious barriers to the accuracy of our memory of our behavior and it's context. We are naturally biased to see ourselves in the right and be suspicious of others. We must learn to correct for our natural biases in order to create a useful theory of our own mind.
There are several skills we can learn and enhance to better understand ourselves and others. Many of these skills are learned in our most cherished relationships, starting with our mothers. We need to be aware of the nature of mental states, that understanding ourselves and others is often difficult and incomplete; people can change their mental state to minimize pain, or disquise themselves. Our interpretations of others are influenced by our own internal states. Feelings often do not follow logic or reason. Mental states evolve from day to day and experience to experience. Parents are highly influential teachers of their children. Their teachings are influenced by that which they learned from their parents. What we learn as children often must be revised based on our adult experiences. Our very presence in a relationship influences the others mental states and in turn our own, often beyond our awareness (Wallin, 2007). Self-knowledge is often difficu... Read more »
Choi-Kain LW, & Gunderson JG. (2008) Mentalization: ontogeny, assessment, and application in the treatment of borderline personality disorder. The American journal of psychiatry, 165(9), 1127-35. PMID: 18676591
Dolan, R. (2002) Emotion, Cognition, and Behavior. Science, 298(5596), 1191-1194. DOI: 10.1126/science.1076358
Kahneman, D. (2003) A perspective on judgment and choice: Mapping bounded rationality. American Psychologist, 58(9), 697-720. DOI: 10.1037/0003-066X.58.9.697
Waller, B., Cray, J., & Burrows, A. (2008) Selection for universal facial emotion. Emotion, 8(3), 435-439. DOI: 10.1037/1528-3542.8.3.435
Westen, D. (1998) The scientific legacy of Sigmund Freud: Toward a psychodynamically informed psychological science. Psychological Bulletin, 124(3), 333-371. DOI: 10.1037//0033-2909.124.3.333
- April 9, 2010
- 02:49 PM
- 484 views
The Essence of Human Experience: What is Normal? Emotional Intelligence for Personal Growth, Part V
by David Johnson, MSW, LICSW in Dare To Dream
This is the fifth in a series of articles on Emotional Intelligence for Personal Growth.
Probably all of us have asked our self from time to time if our thoughts, feelings, or behavior at any single moment is "normal". Actually, there are different answers for each one of these.
Normal behavior is, like it or not, defined by our legal, community (family, neighborhood, social group) and religious institutions. The law is enforced by our local police, and sanctioned by our courts. Religious values might be said to be collectively defined by our church going population and it's leadership. If we are observed behaving outside of legal boundaries, we may find ourselves in a court room facing a judge. If we stretch our community or religious values, we might be ostracized, and separated from the kind of support we have been reliant on through our life.
Our internal life, our thoughts and feelings, that which goes on within ourselves may be our last real privacy. And that is indeed fortunate. Our internal creativity is uncomfortably broad. We are capable of thinking and feeling most anything from time to time. Under provocation, we are capable of thinking about things we would never do. Angry enough, we may think of assault, even murder. Seeing a pretty woman, a married man might think about cheating on his wife, but never act on that thought. Shocked about a death in the family, our first thoughts may be directed at the inconvenience of disrupting out usual routine and our feelings might be closer to annoyed. Our thoughts and our feelings often contradict each other. In a real sense, we live a dual existence.
Duality
Our body speaks to us through our feelings. Messages are typically fast, automatic, effortless, associative, not available to reflection, and often emotionally charged. Messages are also governed by habit and are therefore difficult to control or modify without time and significant effort. Curiously, since the messages do not require conscious awareness, they do not cause or suffer much interference when combined with other tasks.
Our thoughts, however, are relatively slower, serial, effortful, more likely to be consciously monitored and deliberately controlled. Compared to feelings, thoughts are relatively flexible and thus change readily and can be directed by conscious or habitual rules. Because thoughts are effortful, they tend to disrupt each other. Thus monitoring mental operations for quality interferes with monitoring overt behavior. People who are occupied by a demanding mental activity are more likely to respond to another task by blurting out whatever comes to mind.
Intuitive judgments combine the function of feelings and thoughts. The perceptual system and intuitive about perceptions generate impressions of the attributes of objects. These impressions are neither voluntary nor verbally explicit. Judgments are always intentional and explicit even when they are not overtly expressed. Thus, thinking is involved in all judgments and can be reflected upon, whether they originate in impressions or in deliberate reasoning. Monitoring of intuitive judgments is normally quite lax and allows many to be expressed, including some that are erroneous (Kahneman, 2003).
We perceive reality by these two interactive, parallel processing systems.
The rational system , a relative newcomer on the evolutionary scene, is a deliberative, verbally mediated, primarily conscious analytical system that functions by a person's understanding of conventionally established rules of logic and evidence. The experiential system, which is considered to be shared by all higher order organisms (although more complex in humans), has a much longer evolutionary history, operates in an automatic, holistic, associationistic manner, is intimately associated with the experience of affect, represents events in the form of concrete exemplars and schemas inductively derived from emotionally significant past experiences, and is able to generalize and to construct relatively complex models for organizing experience and directing behavior by the use of prototypes, metaphors, scripts, and narratives. Although the experimental system is generally adaptive in natural situations, it is often maladaptive in unnatural situations that cannot be solved on the basis of generalizations from past experience but require logical analysis and an understanding of abstract relations.
[B]ehavior is guided by the joint operation of the two systems, with their relative influence being determined by the nature of the situation and the degree of emotional involvement. Certain situations (e.g., solving mathematical problems) are readily identified as requiring analytical processing, whereas others (e.g., interpersonal behaviors) are more likely to be responded to in an automatic, experientially determined manner. Holding such situational features constant, the greater the emotional involvement, the greater the shift in the balance of influence from the rational to the experiential system (Denes-Raj & Epstein, 1994).
One might ask, why are there two systems? Many of us have at times wished that our emotions could quiet themselves or even go away. Our culture has a bias towards logic and is suspicious of our emotional side. To quote Ayn Rand:
A philosophic system is an integrated view of existence. As a human being, you have no choice about the fact that you need a philosophy. Your only choice is whether you define your philosophy by a conscious, rational, disciplined process of thought and scrupulously logical deliberation - or let your subconscious accumulate a junk heap of unwarranted conclusions, false generalizations, undefined contradictions, undigested slogans, unidentified wishes, doubts and fears, thrown together by chance, but integrated by your subconscious into a kind of mongrel philosophy and fused into a single, solid weight: self-doubt, like a bail and chain in the place where your mind's wings should have grown...
Not matter how much we wish we could be logical and rational, there is a burgeoning literature that says otherwise. Our decisions are evident in our brain activity long before we are consciously aware (For example, see Libet et al., 1983 and Dennett, 2003). We have a dual system of decision making because it works. Think about it. How often to we make decisions where we have all the information we need to be absolutely sure that our logical deduction is correct? I would venture to say that being sure is limited to only our most simple and concrete decisions. Most every other decision involves weighing facts, impressions, intuitions, and feelings and making as best a decision as possible.
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Phineas Gage is perhaps the most famous neurology patient of all time. After a gruesome injury in which he was impaled through his skull by a metal rod and then miraculously recovered, poor Phineas retained all the logic he ever had, but was completely unable to make a decision. He was also left without any awareness or expression of emotion (Demasio, 1994). The very act of making a decision is an emotional process. We choose our decisions among competing alternatives based not only the evidence, but what feels best to us, our "gut level" reaction.
The story behind this dual system is most evident in normal social development.
The Attachment Relationship
John Bowlby (1969/1982) is credited as the founder of Attachment Theory, based on his observations that the quality of a child's social development was largely determined by the quality of the child's relationship with her caregiver. Mary Ainsworth and Mary Main began the research that would ultimately follow children over their first 20 years of development demonstrating Bowlby's concepts to be true and elaborating that theory to account for how, as a child and adult, how freely and effectively she can think, feel, remember, and act (Ainsworth et al., 1978, Main et al., 1985 & Fonagy et al., 2002). Fonagy went on to find that a pa... Read more »
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- May 9, 2010
- 08:00 PM
- 467 views
The Two Darts of Suffering: Pain is Inevitable, Suffering is Voluntary Emotional Intelligence for Personal Growth, Part VI
by David Johnson, MSW, LICSW in Dare To Dream
This is the sixth in a series of articles about emotional intelligence for personal growth. In keeping with the idea that emotional intelligence is one of the foundational concepts of mental health, I dedicate this installment to May, Mental Health Month.
It is often said that life is suffering. Some of that suffering is unavoidable. Life has a way of throwing us adversity. The pain of physical distress and illness as well as the psychological pain of loss is unavoidable. This is the first "Dart" and might be called pain. Pain serves an adaptive function in human life and allows us to appraise our experience and prepare to act in ways to maintain favorable conditions or to change unfavorable conditions (Egloff et al., 2006). Positive emotions encourage us to maintain that which evoked our pleasure. Negative emotions motivate us to avoid or solve the problem that triggered the pain.
Image by mlegg31 via Flickr
Much of our suffering after the initial pain is voluntary. How we react to things, how we talk or think about our experiences often complicates and prolongs the pain. This is the second "Dart". Second darts often trigger more second darts through feelings and thoughts about one's first reaction. For example, you feel guilty about your anger about the first dart. Or perhaps you feel sad about having been hurt again. (Hanson & Mendius, 2009).
The concepts of the two darts of suffering come from the "Pall Canon", one of the earliest teachings of Buddha.
There is a further distinction implied in the metaphor of the Two Darts: that reaction and response are distinctly different modes of behavior, the former a pattern rooted in clinging [to reality as it is] and the latter a spontaneous meeting of phenomena free from impatience and judgment. The first dart refers to the ability to be present with what is arising, unfolding, and passing away in present experience. The second dart is characterized not just by fight or flight, but by the entire self-constructing mechanism of the mind.... Whenever there is clinging, there is a story about "me" that arises from one's reaction to what is occurring in that moment. (Thera, 1983)
Pain signals an abrupt change in our environment, one we at least initially do not like. The pain, in a way, represents the reality we cling to being ripped from our grasp. We then perceive a sense of loss, that slows and focuses our thoughts, prolongs the experience and allows us to mourn and make sense of what's happened to us. What we learn from our losses builds our skills of coping with loss. As we age, the frequency of loss accelerates. Our children grow up and move away, grandchildren grow and no longer need the attention of the grandparents. Our friends and older family members die off ever more frequently. If we fail to master the painful process of grief, it will threaten our mental health with a mind numbing depression, increase the stress on our internal organs, shorten our lives and perhaps threaten our very existence (Goleman, 1995).
How we react to our experiences, how we think and feel about them, largely determines how we extract understanding and meaning from them and how they are recorded in memory. All of the thoughts and memories are recorded in bits and pieces that amount to little more than a skeleton of the actual event. Each time we re-experience this memory, it's recreated from the remaining memory traces, and our more recent experiences fill in the detail. The experience of old distress in the presence of new information, permanently changes the memory, adding the new information. However, without our intervention, the overall structure of the memory and it's accompanied emotions will see little change.
This process of recreation allows us an opportunity to change memory permanently. Our experience over time and the support of those around use who are wiser in this regard, can teach us about this experience us, allowing us to modify the experience and direct how the memory is changed (Hanson & Mendius, 2009).
We have many ways we manage our emotions. Two have been widely investigated: expressive suppression and cognitive reappraisal (see Gross, 2002, for an overview). Expressive suppression is a reactive emotion regulation strategy: It aims at inhibiting ongoing emotion-expressive behavior. Cognitive reappraisal, in contrast, is a planned strategy: It aims at changing how we think about a situation such that the resulting emotional response is modified, e.g., by construing the event as a challenge rather than as a threat (Lazarus & Alfert, 1964). In a typical loss situation, we have both strategies available to us. It's probably best if we suppress some rather dramatic expressions of our pain, lest we scare those around us, damage our relationships or our belongings and distract us to the challenge before us. Shock immediately and sadness subsequently manage our reactions. The shock we feel immediately gives us time when we "know" what has happened to us, yet we are not feeling the emotional effects yet. Presumably, we have a bit more judgment to prepare for a prolonged period of impaired judgment. When we are sad, the perception of time and our reaction times slow. Our grief dominates our experience so much that it is difficult to think of anything else. We find ourselves repeatedly re-appraising about our loss, its consequences, and its implications.
This process is a necessary part of grief. We must feel the distress, experience the emotional arousal as a bodily felt experience, accept and tolerate it as a necessary part of integration and resolution. We must also understand that experience as information, explore, reflect on, and make sense of it, and access other internal and external emotional resources to help transform it to something less distressing. This processing of our experience creates a new perspective reflecting acceptance, making sense of difficult and painful events and creates wisdom in the form of future flexibility and mindful adaptability.
An individual's capacity for emotional processing is not an inherent skill. We learn this skill in the process of early attachment experiences. The more secure the attachment, the more effective our ability to tolerate, understand, integrate, and transform an emotional experience into a new perspective that enables us to better cope with the future. Even if we've not had a healthy attachment in childhood, we are able to acquire that skill as an adult in healthy adult relationships, such as a transformative relationship with a counselor (Greenberg and Pascual-Leone, 2006, pp 614-615).
After we have dealt with the initial pain and begun the process of grief, we will experience other less adaptive emotions. These secondary emotions are at best distracting, at worst maladaptive and may need to be regulated. For example, feeling hopeless can be secondary when there is an suppressed feeling of anger. Maladaptive emotions obstruct and the process of grief and can leave the person feeling stuck, often hopeless, helpless, and in despair. These emotions are inevitably a part of grief adding detail and texture to the assessment of our loss and the envisioning of our future. But they also add to the stress and can prolong the experience without appropriate regulation.
Regulation of emotion essentially involves gaining some psychological distance from overwhelming feelings such as despair and hopelessness, in the short term, and developing self-soothing capacities to calm and comfort core anxieties and humiliation, in the longer term. When one feels a maladaptive emotion such as core shame or a feeling of shaky vulnerability and self-doubt, one benefits from regulation in order to prevent becoming overwhelmed by those emotions, thereby creating the opportunity to make sense of them. Forms of meditative practice, mindfulness and self-acceptance are often very helpful in gaining a working distance from overwhelming core emotions.
Mindfulness treatments have been shown to be effective in treating generalized anxiety disorders and panic, and chronic pain and in preventing relapse. Mindfulness allows for flexibility in affective meaning processes and the interruption of automatic, habitual processes. In short, acknowledging, allowing, and tolerating emotion are important aspects of helping to regulate it. Soothing of emotion can be provided reflexively within one's self or with the help of another person. Among other processes, self-soothing involves diaphragmatic breathing, relaxation, development of self-empathy and compassion, and self-talk. Soothing a... Read more »
Egloff B, Schmukle SC, Burns LR, & Schwerdtfeger A. (2006) Spontaneous emotion regulation during evaluated speaking tasks: associations with negative affect, anxiety expression, memory, and physiological responding. Emotion (Washington, D.C.), 6(3), 356-66. PMID: 16938078
Greenberg LS, & Pascual-Leone A. (2006) Emotion in psychotherapy: a practice-friendly research review. Journal of clinical psychology, 62(5), 611-30. PMID: 16523500
Gross JJ. (2002) Emotion regulation: affective, cognitive, and social consequences. Psychophysiology, 39(3), 281-91. PMID: 12212647
- August 20, 2011
- 10:19 PM
- 413 views
Emotion Regulation: Emotional Intelligence for Personal Growth
by David Johnson, MSW, LICSW in Dare To Dream
This is the eighth in a series of articles about emotional intelligence for personal growth.
Emotions give our experiences a sort of color, a dimension of experience very different from other senses, different from even thoughts. Yet many of us find our emotions at times more of an enemy than a friend. Our emotions serve a purpose, one that is not entirely obvious.
Most current theories of emotion share the assumption that emotions serve an adaptive function in human life. Emotions play an important role in how we appraise and prepare to act on current circumstances. There are instances when emotions seem to interfere with what we do. The simplest examples are of anxiety reactions to public speaking, climbing ladders, or spiders. 'Emotion regulation' is a popular way of describing a solution to this problem.
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Gross (2002) attributes the roots of the study of emotion regulation to Freud's early psychoanalytic theorizing about the nature of psychological defenses and Lazarus' stress and coping tradition. He describes two forms of emotion regulation. Reappraisal involves changing how we think about a situation in order to decrease its emotional impact. Suppression involves inhibiting ongoing emotion-expressive behavior. The method of reappraisal involves reinterpreting the emotional trigger into something less provocative. Suppression involves catching the reaction after it begins and containing it's consequential behavior.
However, this is a rather simplistic description of a complex process. The very act of suppressing the target emotion evokes more emotions. An emotional response that invites suppression might evoke embarrassment at the intensity of the reaction, fear about the consequences of inadvertent expression, and shame about not having learned from similar experiences in the past. Cognitive reappraisal is strategy that can be useful to head off a response, but is possibly even more useful as a method to review the experience after the emotion has been contained. It seems to me that there are few examples I can think of that don't involve both strategies more or less working together.
Gross & Levenson (1993, 1997) notes that expressive suppression can lead to decreased emotion expression, but interestingly, the body seems to feel the emotion even more intensely as reflected in increased sympathetic activation. Emotional suppression reduced memory for details emotional events, while reappraisal had no effects on memory.
Reappraisal may be related to relabeling and sublimination. Relabeling involves a cognitive reassignment of meaning that changes the qualitative emotional response, perhaps even it's valence. Sublimination is the directing of emotionally based response tendencies (motivation) into constructive problem solving responses that address the situation that elicited the emotion. Relabeling may play an important role in sublimination by redirecting energy into a more productive direction, presumably making it even more directable. Relabeling a suppressed emotion and subliiminating the motivation into a constructive response allows greater adaptive potential, memory, and interpersonal functioning.
Gross (2002) argues that suppression--as a response-focused strategy-- acts comparatively late in the regulation process. Thus, the emotion is already underway and thus the energy implied in the sympathic activation is no longer available to be redirected. The decreasing in expressive behavior has some side effects in terms of cognitive (impaired memory) and physiological costs (increased sympathetic activation). Suppression does not diminish negative emotions. In contrast, reappraisal theoretically takes effect before the emotion response tendencies have been triggered leading to fewer behavioral and experiential signs of emotion without increasing physiological responses or impairing memory. However, it's hard to imagine that a person could have perceived the emotional trigger and selected an alternative interpretation without experiencing the emotion. Emotional processes is known to be much quicker than the more methodical and step by step rational process (Kahneman, 2003). I think it's reasonable to assume some suppression is required to enable the time to reappraise, then the emotion is redirected into it's alternative conceptual context. Since reappraisal is known to decrease emotional activation, one must assume that the energy is redirected somewhere in a way that prevents most sympathetic activation. Redirecting the energy into motivation towards a constructive solution (sublimination) seems a likely explanation. Sublimination may well be regular part of the reappraisal process.
Gross and John (2003) found that the habitual use of both strategies is uncorrelated. That might be explained by a conscious or pre-conscious choice. Suppressing an emotion might be a decision distinct from brief suppression followed by reappraisal and sublimination. Perhaps suppression is used because an obvious reappraisal strategy is unavailable or the person has an underdeveloped reappraisal skill. One has to wonder what happens to the energy. Invitably, the emotional activation will be expressed cognitively. Strong activation requires an explanation. If there is none, then feelings of helplessness and anxiety can spiral into being overwhelmed quickly. Few people will have the ability to supress the emotion with denial, but anger and blame towards some external source might head off a spiraling cycle of anxiety and helplessness. One would expect that such unspoken expression of emotions to be incomplete, even unsatisfying, and create an expectation of more negative outcomes. This would appear to be a largely maladaptive strategy.
Gross and Thompson (2007) describe emotion regulation as one of four types of affect regulation. "Coping" is solely focused on decreasing negative affect across greater periods of time and multiple instances. They define mood as a global more persistent set of affect than an emotion and it's regulation as a means to manage the experience and action tendencies it may evoke. Emotion refers to one single meaningful event. It's regulation is focused on managing the experience and behavior tendency (motivation) it evokes evokes.
They describe five families of emotion regulation.
Situation selection involves planning to minimize any possible distracting or destructive emotions, by taking actions that make the desired outcome more likely. This is an important method used by parents during the life of a young child. A parent might recall a previous fantasy play at home with a toy doctor's bag to explain and distract the child during a visit to the doctor.
Situation modification involves quick actions that change the situation to one in which the outcome is more favorable. Very little planning is involved, though the skill might be developed by practicing and role playing. Supportive and empathetic responses to children's expression of emotion lead to more effective coping. Angry, denigrating, or dismissive responses undermine emotion regulation. An example might include bringing a book or activity to use during a waiting room period.
Attentional deployment involves directing one's attention within a given situation such as distraction, concentration, leaving, refocusing. This is probably how people suppress thoughts. Trying not to think about something is usually an exercise in futility. Replacing the thought with something incompatible is pretty effective. At least some cognitive restructuring is an example of attentional deployment. For example, you can refocus on past successes in solving problems when stuck with a current one. A glass is half-full, rather than half-empty.
Cognitive change involves altering the emotional significance of the appraisal by changing the meaning or changing one's capacity to manage the emotion. Cultural differences in socialization may play heavily on this skill, it's flexibility and effectiveness. Deciding that someone's inattentiveness caused them to bump into you, rather than a deliberate attempt to disrupt what you were doing would be an example of alternating the emotional significance of the event.
Response modification is the method that is used after the situation is perceived and a response is initiating. This method involves influencing the physiological, experiential, or behavior responding as directly as possible. Drugs, exercise, relaxation, alcohol, cigarettes, medication, and food have been used this way. You can also modify how the thoughts and emotions are expressed. An important consideration is the situatio... Read more »
JAMES J. GROSS. (2002) Emotion regulation: Affective, cognitive, and social consequences. Psychophysiology. DOI: 10.1017.S0048577201393198
- January 11, 2012
- 03:39 PM
- 120 views
The Existential Experience of the Trauma Should Be the Focus of Treatment in PTSD
by David Johnson, MSW, LICSW in Dare To Dream
How we integrate or make sense of our experiences have a lot to do with how they affect us. That's just common sense. However, the drive within psychology towards a research and evidence based practice standards has led to a move away from seeking the consensus of practicing professionals in the field on the formation of theory. A theory informed practice has been the standard for many years. Experts construct a theory based on their professional knowledge, including research. The theory is then tested based on the defined concrete references of the theory, called operational definitions. This is a very common approach to theory construction. For example, testing the theory that the planets orbit the sun, one mathematically works out where each planet should be at some set time in the future based on the theory. When they are found there, that provides one study supporting the criterian validity of the theory that the the planets orbit the sun.
The problem is that psychological constructs are notoriously defined differently by different researchers, and there is little consensus on a grand theory that attempts to explain human behavior. Instead there are a number of theories that have been developed that accounts for behavior based on the thoughts that occur before the behaviors. Research has shown that behavior can change when thoughts about that behavior change. This has been replicated many times. Cognitive behavior therapy is the model in the psychology that enjoys the largest following. But this theory does not explain all or even most behavior, nor does in fit with some of the more common beliefs and assumptions about human behavior.
If changing one's thinking were all that was necessary to change behavior, then more people would be successful with New Year's resolutions. Most people will tell you of their dismal success breaking old habits in the New Year. Throughout 2007, one study tracked over 3000 people attempting to achieve a range of resolutions, including losing weight, visiting the gym, quitting smoking, and drinking less. At the start of the study, 52% of participants were confident of success. One year later, only 12% actually achieved their goal.
Another problem with Cognitive Behavior Theory (CBT) is that it assumes that emotions are just an another form of behavior caused by thoughts. In some cases this may be true. In generally healthy people, emotional issues may well respond to changes in thoughts. But it's clear that Post Traumatic Stress Disorder (PTSD) is largely an emotional disorder, where manifestations have incomplete connections to thoughts. CBT is not the treatment of choice. Some form of exposure therapy is widely used to essentially break the pattern of emotionally driven habitual behavior or extinguish the conditioned emotional responses to thoughts, feelings and external stimulation associated with the trauma. If you experience that memory and it's emotions in a safe setting and recognize that your fears were not realized, then the memory is changed with the addition of this new information. This sort of change is incremental. Such learning may need to be repeated several times the intensity of the emotion subsides to acceptable levels.
Other clinicians see a more profound version of PTSD in combat veterans.
Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerilla wars amplify these challenges. Potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally, Image by Getty Images via @daylifepsychologically, behaviorally, spiritually, and socially (what we label as moral injury). Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury. (Litz et al., 2009)
Georgetown University ethics professor Nancy Sherman heard stories of moral trauma when she interviewed veterans of Iraq, Afghanistan, Vietnam and World War II for her 2010 book, The Untold War. "It might be where you felt you should have been able to do more for your buddies, but you couldn't, or because you simply survived," she says.
"Regret," she writes, "doesn't begin to capture what the soldiers I talked with feel. It doesn't capture the despair or depth of the feeling -- the awful weight of self-indictment and the need to make moral repair in order to be allowed back into the community in which he feels he has somehow jeopardized his standing." (Silver, 2011)This is not a new idea, but rather repackaging of a well documented feature of all trauma, and not just trauma related to combat. Themes of shame and guilt pervade the PTSD literature, often referred to as complicating factors.
Studies suggest that those who interpret a traumatic experience as intensely negative are more at risk for posttraumatic distress and disorder than those who view the event as less traumatic. Specifically, a woman's reaction at the time of her victimization is likely to be an important predictor of her later psychological state. (Briere & Jordan, 2004)
Certainly conceiving of a victim's behavior during a traumatic event as transgressions of deeply held moral beliefs and expectations would qualify as a particularly negative interpretation of the event and thus predict a more difficult recovery. She is also more likely to develop a shame-based view of herself based on the conclusion that she has demonstrated a moral defect reflected in her behavior. In my clinical work, I've seen this phenomena in traumatization caused by crime victimization, particularly rape, in natural disasters, such as hurricaine Katrina and the Northridge earthquake in Oakland, Ca, as well as combat trauma from Iraq, Afghanistan and Vietnam. The complicating factor of shameful beliefs about personal responsibility when others are injured is a prominent feature in people struggling with a difficult recovery.
This new conceptualization of moral injury may come in a useful form, one that is easily understood by the client and destigmatizing in the sense that a "mental health" problem is consistent with cultural norms. In addition, the authors further the theory of PTSD and its notorious resistance to treatment. The shame of a moral injury leads the sufferer to withdraw from social contact even with close confidants, under the assumption that if she doesn't hide their shameful behavior, others will know and find her disgusting and worthy of rejection. This prevents the natural healing process of sharing and reexperiencing the trauma with the support of a loved one. The expression of love and acceptance despite their shameful behavior becomes part of the emotional memory and gradually attenuates the shame as well as the intrusive memories, nightmares and flashbacks. The authors note that self esteem has been found to mediate between belief that the world is just and in the willingness to self forgive Therefore, self-esteem may be an protective factor from moral injury. The authors also note that PTSD as well as moral injury involve healthy feelings. The affliction of a moral injury is in part a believe that the sufferer is not worthy of self-forgiveness. (Litz et al., 2009)
Litz et al., (2009) outlines a model they call a "modified CBT" approach. They describe eight components: 1. A strong working alliance. 2. Educating about the concept of moral injury and preparing a plan for change. 3. a "hot-cognitive" exposure based processing or emotion focused self-disclosure. 4. A thorou... Read more »
Litz, B., Stein, N., Delaney, E., Lebowitz, L., Nash, W., Silva, C., & Maguen, S. (2009) Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. DOI: 10.1016/j.cpr.2009.07.003
- November 22, 2011
- 09:24 PM
- 78 views
Facebook Depression: Another Media Frenzy
by David Johnson, MSW, LICSW in Dare To Dream
I'm going to try to write more short posts rather than work on a big paper for months before I post.There is a lot of hype about Facebook causing depression citing research. Actually, if you look, you will find the research had nothing to do with Facebook.Image via CrunchBaseIt all started with this article writing on this research article where the author rather loosely used the term "Facebook depression". There is of course no such thing as Facebook depression. The author submits her disclaimer here.All the more reason to read about research in the media with considerable skepticism. Here is a past article I wrote on the topic.There is reason to be concerned about spending long hours doing anything, including Facebook and the Internet, that could contribute to the development of depression. The causes are much more complex.
Reference O'Keeffe, G., Clarke-Pearson, K., & , . (2011). The Impact of Social Media on Children, Adolescents, and Families PEDIATRICS, 127 (4), 800-804 DOI: 10.1542/peds.2011-0054
Related articlesFacebook Depression: Social Media and Children (sixestate.com)
... Read more »
O'Keeffe, G., Clarke-Pearson, K., & , . (2011) The Impact of Social Media on Children, Adolescents, and Families. PEDIATRICS, 127(4), 800-804. DOI: 10.1542/peds.2011-0054
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