Sunday, December 10, 2017

The Imposter Syndrome, Competency, Self-Esteem and Rejection

When you apply for a job, enter a contest or a race, or even ask someone on a date, you are making an evaluation of your intelligence, strength, charm and wit, and you are assuming that you have a reasonable chance of success. You are both guessing about the complexity of the challenge, and estimating your ability to meet that challenge. For some, repeated rejections can crush their internal sense of self-worth. We may get tired of trying, and only make efforts which are safe, that we are sure we will succeed at, or we may decide to avoid the activity completely in the future. Avoidance of rejection can become a way of life, and this can be crippling. For those who ignore feedback or simply don’t get feedback they may perform endlessly without improvement, believing that their talents are unmatched, and either torturing or alienating those around them.

In The Narcissism Epidemic the third chapter challenges several myth’s about the narcissist, specifically the idea that some narcissism is good. Twenge and Campbell write:

Our culture tells us it pays to believe in yourself as long as you aren't arrogant or narcissistic. However, this isn't really true [...]. A major review of the research on self-esteem and achievement found that high self-esteem does not cause better grades, test scores, or job performance. It's a problem of correlation not equaling causation. There is a small correlation between self-esteem and better achievement, but it is almost entirely explained by better performance causing higher self-esteem. Self-esteem comes after success, not before, because self-esteem is based on success (whether that's academic success or simply being a good friend to someone). Much of the rest of the already small link is due to confounding variables- rich kids, for example, have higher self-esteem and make better grades. Some children with low self-esteem do poorly, but it's because they were abused or had parents who did drugs- things that cause both low self-esteem and poor outcomes. On its own, self-esteem does not lead to success.



Think about it this way: if self-admiration caused success, American children, who have the highest self-esteem of children anywhere in the world, would also be the most successful. This simple prediction, however, doesn't match the data. In a recent study, 39% of American eighth-graders were confident of their math skills, compared to only 6% of Korean eighth-graders. The Koreans, however, far exceeded the U.S. students' actual performance on math tests. We're not number one, but we're number one in thinking we are number one.

Wikipedia describes the Dunning–Kruger effect as a cognitive bias where people of low ability suffer from illusory superiority, mistakenly assessing their cognitive ability as greater than it is. The cognitive bias of illusory superiority derives from the metacognitive inability of low-ability persons to recognize their own ineptitude; without the self-awareness of metacognition, low-ability people cannot objectively evaluate their actual competence or incompetence. This isn't necessarily a problem of an overactive ego, or excessively high self-esteem, but rather it is our own inability to estimate how good we are at doing things that creates the problem.



There is a good video on YouTube titled: Why incompetent people think they're amazing. It describes several studies, one done at two separate computer companies where the programmers were asked to provide a rating for their own performance. At the first company 32% rated themselves among the top 5%, while at the second company over 60% of the programmers rated themselves in the top 5%. In another study 88% of American drivers described themselves as above average and more competent behind the wheel than most others. This same effect, where individuals overestimate their ability can be demonstrated for all sorts of skills, activities, and attributes. The vast majority of people simply believe that they are above average at most things. Numbers like these violate the simple law of averages which states that the odds of you being a little worse than average at some task are about equal to the odds that you are better than average at some other task. Those with the least ability are most likely to overrate themselves by the highest degree. Poor performers lack the very expertise needed to understand the problems with what they are doing.

People are exceptionally bad at estimating how good they are at something, and not only does this apply to the incompetent who wildly overestimate their abilities, but it also applies to experts who tend to do the opposite and underrate their abilities.

Graduate students, professors, and other high achievers often suffer from a phenomena called the imposter syndrome. Wikipedia provides a good overview:

Individuals who suffer from the impostor syndrome have a marked inability to internalize their accomplishments and a persistent fear of being exposed as a "fraud". The term was coined in 1978 by clinical psychologists Pauline R. Clance and Suzanne A. Imes. Despite external evidence of their competence, those exhibiting the syndrome remain convinced that they are frauds and do not deserve the success they have achieved. Proof of success is dismissed as luck, timing, or as a result of deceiving others into thinking they are more intelligent and competent than they believe themselves to be.

[Several behaviours are common to those that suffer from imposter syndrome]:

Diligence: Gifted people often work hard in order to prevent people from discovering that they are "impostors". This hard work often leads to more praise and success, which perpetuates the impostor feelings and fears of being "found out". The "impostor" person may feel they need to work two or three times as hard, so over-prepare, tinker and obsess over details. This can lead to burn-out and sleep deprivation.

Feeling of being phony: Those with impostor feelings often attempt to give supervisors and professors the answers that they believe they want, which often leads to an increase in feeling like they are "being a fake". If shown evidence of their competence or that they may suffer from a case of impostor syndrome, they tend to doubt themselves even more.

Avoiding display of confidence: Another way that a person can perpetuate their impostor feelings is to avoid showing any confidence in their abilities. A person dealing with impostor feelings may believe that if they actually believe in their intelligence and abilities they may be rejected by others. Therefore, they may convince themselves that they are not intelligent or do not deserve success to avoid this.


As described by social psychologists David Dunning and Justin Kruger, the cognitive bias of illusory superiority results from an internal illusion in people of low ability and from an external misperception in people of high ability; that is, "the miscalibration of the incompetent stems from an error about the self, whereas the miscalibration of the highly competent stems from an error about others." Hence, a corollary to the Dunning–Kruger effect is that persons of high ability tend to underestimate their relative competence and erroneously presume that tasks that are easy for them to perform are also easy for other people to perform.

While the imposter syndrome is not described in the standard manual of psychiatric disorders (DSM-IV or DSM-5), it is a risky state of mind. Underrating your physical abilities might deter you from joining an exercise group which would otherwise welcome a new member, and this might represent a missed opportunity for socialization. Such decisions, while not catastrophic, are unfortunate. Genuine mental health issues often result from similar distorted perceptions of reality, and these can take many forms. In extreme cases, a person may begin to doubt their competency at relatively basic tasks. When feelings of incompetency and being an imposter make their way into your day-to-day life, like being unable to ride the bus because you believe you won’t understand the route or the schedule, or feeling rejected by others in simple situations like going to a grocery store or a bank, then a false self-evaluation can wreck real havoc in your life.

In MHTWT there is a chapter titled: “The Passion for Self-Distrust”, Low writes:

My patients have gone through months or years of torture and in the process developed sustained tenseness and symptoms attending it. Their weariness, their pains, fatigues, pressures and spasms have made them self-conscious in the extreme. Hence, they lack the feeling of vitality and accomplishment; they have lost their self-confidence, are unable to relax or enjoy things. Required to formulate plans and intentions they are instantly gripped with the fear that their muscles will fail them, that they will not be ready to carry out what they are asked to do. Being the victims of an unrelenting self-consciousness they question their capacities, watch and check every one of their moves and perform with hesitation and anxiety. Their attitude is that of an abiding pessimism; they feel whipped and defeated; their guiding philosophy of defeatism has hardened into a settled conviction. They are "sure" and "certain" and "positive” that acting is impossible, that their muscles will defy orders, that their power to get things done is lost, that their personality functions are doomed. Their philosophy of "I can't" has assumed the status of a dogma; it is implicitly believed, hotly defended and fondly sheltered. The calamity is that the relatives and friends do not share the patient's defeatism and refuse to subscribe to the cult of "I can't." They look at the sufferer and notice a blooming complexion, a strong voice, a lively facial expression. They observe the patient in a fit of his frequent tantrums and witness a display of force and energy which belies the claim to invalidism. Their conclusion is that the patient could but would not do the things which are to be done. The idea is forced on them that he is unwilling instead of unable to perform his function. They upbraid him, urge him to make an honest effort and with this they accuse him of shamming disease, of playing a game, of practicing deception. They indict his character, his honesty; they charge him with deliberate neglect of duties and obligations and fasten the label of irresponsibility on him. This strikes at the root of his self-respect, of his personal value and social position. This savage assault must be repelled. The patient feels he must bend every ounce of his energy to the vital task of convincing the others that he "really" can't, that he is "truly" incapable of acting, that he is "positively" helpless. The patient is now a crusader for the philosophy of "I can't." He concentrates on the effort to win over the others to his dogma of defeatism, to make converts, to spread the gospel of his incurability. In order to convince those about him, including the physician, he must engage in a veritable campaign of complaining, wailing, lamenting. In his interminable moaning and groaning he is compelled to overemphasize the utter unreliability of his organs and functions. His body is forever about to crumble, his mind is constantly ready to disintegrate. As he continues on this career of self-denunciation he fairly gorges himself with the idea of distrust and in the end develops the PASSION FOR SELF-DISTRUST. His untiring crusading for the philosophy of "I can't" has netted him one faithful and unswerving convert: himself.

Rather than thinking about this information in the context of judging or criticising someone you know who claims that they are either awesome or incompetent, when you are sure that they are perfectly average and neither an expert nor a total failure, it’s more valuable to apply this information to yourself. In Recovery we say “Expectations can lead to disappointments”, and while it’s true that when you apply for a job (ask someone on a date, enter a marathon race etc.), you have a certain expectation that you are probably qualified and might get what you are hoping for, it is important to remain less focused on the outcome and more focused on putting in a good effort. Keep in mind that you will probably not have a good understanding of exactly what the other person is looking for, or who you are competing against, and that you may misjudge your own abilities. This confusion is average. It is average for people to need to experiment to understand their own abilities, and it is average to never get a full picture of how you rate against everyone else. In Recovery we say “Mistakes are healthy, wholesome and necessary” and that without mistakes we can’t learn.


Having unrealistic expectations for yourself and others is a cognitive distortion that can lead you into serious trouble. Asking for feedback from someone you respect and trust, and learning to seriously listen and accept the advice that they offer, regardless of how difficult it is to hear, can go a long way towards helping you to understand your own abilities. Recognizing your mistakes and removing your expectations about the outcomes that a task might have can provide you with a tool that will ultimately make you feel better about your progress, and help to improve the progress that you do make. At Recovery meetings we don’t assess, criticize or evaluate members, instead we try to help attendees build skills that will allow them to be self-critical in a realistic way, without being self-congratulatory or self-condemning. We discuss being average, reducing or eliminating our expectations, and being tolerant of our own mistakes and the mistakes made by others. It's hard to know what you can or can't do without trying, and when we try new things we risk failure and rejection. While this is difficult, it is an important path towards mental health. We encourage you to come and meet us. All of our members were new at one time, we understand how difficult it can be to be the new person at a meeting.


More Information

Thursday, November 30, 2017

Diagnoses, Labels and Sensitivities

The list of labels available to those seeking a diagnosis can be long. Depression, anxiety and being stressed are common terms that many people feeling unwell use to describe their own state of mind. Generalized anxiety disorder, bipolar 1 and bipolar 2, manic depression, dysthymia, cyclothymia, major depressive disorders, obsessive compulsive disorder, or persistent depressive mood disorder are more complex diagnoses that might be provided by a psychiatrist. Schizophrenia, multiple or split personality disorder, dissociative identity disorder, and borderline personality disorder are diagnoses which many people confuse and think are related, although have very distinct symptoms. Fibromyalgia, post traumatic stress disorder, chronic or persistent pain, autism spectrum disorder, panic disorder, and misophonia are other labels which many people are aware of. Given all of these terms and specific disorders, how is one to proceed?

A diagnosis is helpful if there are clear and well known cures for an ailment, and this is the case with some physical diseases. The flue and a broken arm are easily differentiated by a layperson and knowing exactly what is wrong with you in cut-and-dry cases like these will facilitate a good recommendation from a doctor; a plaster cast for the broken bone, rest and fluids for the flue. Psychiatric illnesses are sometimes well defined, although even common varieties like depression may not be obvious to an individual when they first encounter the symptoms.

The psychiatrist I saw in the late 1990s agreed with my report that I was depressed, and at one point during the time that I saw him he suggested that a diagnosis of cyclothymia might be more accurate, but he didn't lean on this idea too much. At the time I was pleased to have this better and more precise diagnosis- to me it meant that I had something unusual wrong with me, not just garden variety depression! My psychiatrist didn't make much of this idea and as I recall he only commented on it once or twice which I think was ultimately helpful. The precise label that was applied to what was going on in my life wasn't nearly so much an issue as the symptoms that I had, and this is what we worked on.

There is an unusual 1995 film called "Safe" starring Julianne Moore. Julianne Moore plays Carol White an unremarkable suburban homemaker living in the San Fernando Valley. She lives in a lavish pastel home and spends her time decorating the house with the assistance of a Spanish speaking house keeper named Fulvia and the various hired workman who paint, deliver furniture and assist her. She goes to aerobics classes. She meets her friends for lunch and discusses bland topics with them like the new fruit diet that she tries briefly, and the fact that she seems to not sweat during exercise. In the first part of the film she feels "unwell", and after having several fainting spells, and vomiting in unusual scenarios, often after exposure to cosmetics or car fumes, she decides to seek treatment. She goes to see her doctor who can find nothing wrong with her, and after several visits he refers her to a psychiatrist.

Carol doesn't feel comfortable talking to the psychiatrist, and eventually sees an allergist who confirms that she does have reactions to certain substances that seem to be responsible for her attacks. Carol finds a flyer at her gym that asks the question "Do you smell FUMES?" and after attending a seminar she decides that the best explanation is that she is suffering from "environmental illness". At the mid point in this story it turns very dark. Carol stops wearing makeup, gives up her fashionable skirts for loose track pants and sweaters, and struggles with her relationships. As she begins to look more unhealthy and bedraggled she starts to carry a small green oxygen tank and mask with her so she can breath easily. She rejects her affluent chemical based lifestyle and sets up a toxin free room in her home completed by simple wood furniture upholstered with non-toxic white cotton materials. Eventually she decides that the chemical free room in her house in the valley is not pure enough and she leaves her husband and step son to go stay at a desert retreat for people with environmental illnesses called the Renwood center.

Every time I watch this film I have a number of strong reactions to it. What makes this film so difficult to watch isn't a the cool relationship between Carol and her distant generic businessman husband Greg, or the depiction of the peculiar illness that Carol has or the presentation of environmental issues. What is unpleasant about this film is Carol's conduct and values. She is dull, disengaged, mono-syllabic and stilted in the way she expresses herself. Initially she seems entitled, unaware of her privilege and easily upset- one of her major crises at the beginning of the film is an argument between herself and a furniture store clerk about the color of the couch that was delivered to her house. The clerk shows her the original order and points out that it specifies a black couch, she plaintively whines that this is "...impossible because black doesn't go with anything we have". This quick sketch of superficiality and poor interpersonal skills in many ways defines who Carol is.


While the film presents seriously the idea that living in a chemically laden environment is unhealthy, and seems to convince us that this is a large part of Carol's problem, environmental illness is not the core theme of this film, rather it just provides a backdrop and is what frightens and drives Carol. Carol's confusion, lack of depth and poor choices are at the heart of this story. While watching Carol deteriorate is difficult, its how this film makes me feel about Carol when I watch it that makes my skin crawl. I always find Carol's demise both terrifying and pathetic at the same time. Julianne Moore's outstanding portrayal of Carol leaves me feeling repulsed by her lack of sincere and meaningful values, judgmental about her inability to acknowledge those around her and feeling sympathy for the predicament and illness that her vacuous life has resulted in.

No one in this story seems to genuinely care about Carol. Her husband, doctors, psychiatrists, friends, and even the people at the retreat are dismissive with her and speak to her with either shallow reassurances, or condescending indifference. Ultimately what is frightening about Carol's illness is imagining ourselves in that position, a person suffering from a vague and undiagnosable disease, who generates little sympathy from her family and friends and is largely ignored by those around her.

She connects briefly with a group of patients at the retreat who make her a cake for her birthday and ask her for a speech, she says:

"I couldn't have done it without you... I don't know what I'm saying, its just that I really hated myself before I came here, and ... um, so I'm trying to see myself hopefully ... um, more as I am, more ... um, more positive, like seeing the pluses, like I think its slowly opening up now people's minds like ... um educating and ... and AIDS and other types of diseases ... 'cause ... 'cause, and it is a disease 'cause its out there and we just have to be more aware of it ... um make people aware of it, even ourselves like and going ... reading labels and going into buildings ..."

This film doesn't provide a standard narrative of illness, where we might expect the protagonist to die, leaving friends to mourn or revile their passing, or gets better and rediscovers life and possibly is forced to atone for past misdeeds. Instead this film simply doesn't give a lot of answers. One interpretation is that Carol is cursed with an undiagnosable illnesses that isn't resolved as the price for failing to find solid values in her life, but I think this may be highlighting the wrong message from the story. It may be simpler than this; that toxins and meaninglessness are part of American affluence and can happen together, that medicine doesn't have all the answers, that there are many individuals who are chronically unwell and don't have accepted explanations for what is wrong with them. While the Renwood retreat offers Carol some support the cure provided there doesn't seem effective as Carol's condition deteriorates up until the end of the last scene of the film. Ultimately Carol is isolated and unwell at the Renwood retreat living in a tiny igloo-shaped porcelain lined environmentally-pure safe-house. The thin meaning that Carol finds in learning about the toxins of modern living and how to minimize the impact of those poisons is not enough to cure her physically or spiritually.


I've watched this film many times over the years. The first time I saw it I hated it, but I remembered every detail. I've come back and watched it several times since then, I think partly because I struggle to understand it. "Safe" is an eloquently painted train wreck, a modern fairy tail of the most hideous kind. It isn't a psychological thriller or horror film in the standard sense, its a tragedy of a person consumed by a vague and undefined illness, for whom grasping at a diagnosis doesn't lead to a cure, and who doesn't get better. "Safe" is a compelling film because it plays on common, but often unacknowledged fears; a vague malaise, odd labels, whether others see us as inventing and diagnosing our own problems, the coldness of modern medicine, and whether unconventional group therapies can have any effect, or provide a refuge for an empty life.

While there are truths embedded in this film, Carol's story is not an average one. One of the key truths is that illnesses are often mysterious, and treating a diagnosis as a definition of who you are is not helpful. Carol's trajectory from meaningless affluence to commune therapy based isolation is something that we fear, but not something that frequently happens.

At Recovery meetings we follow a simple recipe for change through Cognitive Behavioral Therapy. The methods we employ are well documented, and there are numerous scientific studies that attest to their effectiveness. We don't try to diagnose what is wrong with those who attend, and we don't discuss psychiatric conditions in any depth. We accept that people struggle with fear, anger and other complex negative feelings and we provide simple recipes for dealing with these issues. We strongly recommend that attendees have a doctor evaluate any physical symptoms that they have to rule out physical conditions. We understand that many attendees have met with a psychiatrist or a therapist and may have been given a specific diagnosis, although we don't delve into these details. We acknowledge that nervous persons are afraid of being permanently handicapped, and afraid of set-backs. While these fears may be real and common, they are only based in partial truths. Depression is the common cold of mental illness, and while difficult, destructive and hard to understand, it is something that people recover from.


More Information

The Biology of Depression's Vicious Cycle

Mental Health Myths, Inkblot Tests and Electroshock Therapy

Fear is the Mind Killer

Tuesday, November 21, 2017

Narcissism, Self-Esteem and Humility

2008 New York Times article states that narcissism has become the go-to diagnosis for "... columnists, bloggers, and television psychologists. We love to label the offensive behaviour of others to separate them from us. 'Narcissist' is among our current favourites." While 'Narcissist' may be a pointed and popular label, it is also a real category of psychological dysfunction. Understanding the narcissist can help us to recognize this difficult trait in others, and more importantly this same understanding can help us to recognize problematic issues in our own behavior that we can work on changing.

The film "Wall Street" provides an archetypal portrayal of 1980s excess and narcissism. Michael Douglas plays the role of Gordon Gekko a wealthy and unscrupulous corporate raider. Gekko is suave, charming, powerful, and seemingly an expert at making money by working the stock market. The idea that self-fulfillment at all costs is a reasonable value and a higher truth- is what many remember this film for. While the film focuses on the conflict between Gordon Gekko and Bud Fox (played by Charlie Sheen), a junior stock broker that Gekko works with and who ultimately betrays Gekko to the authorities for insider trading, the most frequently quoted line from this film are the first words from a speech given by Gekko where he declares that "Greed is Good." Gekko is the classical embodiment of the narcissist; vain, self-assured, charming, aloof and disinterested in the plight of others. Characters like this force us to pause and ask the question; is there value in greed? Is Gordon Gekko right in some sense?

Narcissism has become a popular buzzword used to explain the behavior and apparent success of individuals ranging from Donald Trump, through the late Steve Jobs and the infamous Paris Hilton. As a label it is often used as shorthand for "self-absorbed jerk". From a psychological perspective Narcissistic Personality Disorder is a codified set of behaviours that often present together and can create havoc for both the narcissist and those around them. There is an excellent book called "The Narcissism Epidemic: Living in the Age of Entitlement", written by Jean Twenge and Keith Campbell that investigates narcissism, how it originates in our culture, the impacts of this disposition, and what we can do about it.

According to Twenge and Campbell narcissists are not just confident, they are overconfident, and- unlike most people high in self-esteem- they place little value on emotionally close relationships. Their belief in their superior attractiveness, competency, and intelligence is usually not based in reality but nevertheless is their driving force and both defines their motivations and the rewards that they seek. Maintaining the fantasy of their inflated self-importance is expensive, and the narcissist will happily destroy others or themselves in the maintenance of their narcissistic supply, or those people and activities that reinforce their unrealistic ideas of self. Twenge and Campbell write:

Understanding the narcissism epidemic is important because its long-term consequences are destructive to society. American culture's focus on self-admiration has caused a flight from reality to the land of grandiose fantasy. We have phony rich people (with interest-only mortgages and piles of debt), phony beauty (with plastic surgery and cosmetic procedures), phony athletes (with performance-enhancing drugs), phony celebrities (via reality TV and YouTube), phony genius students (with grade inflations), a phony national economy (with $11 trillion of government debt [USA in 2008], phony feelings of being special among children (with parenting and eduction focused on self-esteem), and phony friends (with the social networking explosion). All this fantasy might feel good, but, unfortunately, reality always wins. The mortgage meltdown and the resulting financial crisis are just one demonstration of how inflated desires eventually crash to earth.

...

Narcissism causes almost all of the things that we had hoped high self-esteem would prevent, including aggression, materialism, lack of caring for others, and shallow values. In trying to build a society that celebrates high self-esteem, self-expression, and "loving yourself," we have inadvertently created more narcissists- and a culture that brings out the narcissistic behavior in all of us.

Many believe in the message from Wall Street, that "Greed is Good." This myth is in part what allows narcissists to influence society. They are often promoted within organizations, sometimes because they can perform well in the short run, but often because they seem like a good choice and are able to charm their way to the top. As romantic partners they can seem exciting and interesting, and the collection of traits that they exhibit, even if only indulged in moderately, can seem pleasurable and reasonable when we act them out on a small scale. Twenge and Campbell provide a summary of several myths about narcissists, and include notes on the relevant studies that illustrate their point.


Myth #1: Narcissism is "Really High" Self-Esteem

Narcissists do have high self-esteem, but narcissism and self-esteem differ in an important way. Narcissists think they are smarter, better looking, and more important than others, but not necessarily more moral, more caring, or more compassionate. Narcissists don't brag about how they are the most thoughtful people in the world, but they do like to point out that they are winners. People merely high in self-esteem also have positive views of themselves, but they also see themselves as loving and moral. This is one reason narcissists lack perspective- close relationships keep the ego in check. Narcissists have no interest in caring for others, which is why their self-admiration often spins out of control.


Myth #2: Narcissists are Insecure and Have Low Self-Esteem

Many people believe that narcissists are actually insecure and "hate themselves deep down inside." Their self-importance, this theory goes, is just a cover for their deep-seated doubts about themselves. This idea can be traced back to the speculation that narcissism is a defense against an "empty" or "enraged" self, hidden low self-esteem, or a deep seated sense of shame. The "cover for insecurity" model of narcissism is pervasive in our culture. On TV's ER, a coworker confronts a mean, bitingly sarcastic surgical resident by saying: "What is it about your need to belittle other people? Does insulting someone make you feel like a man, bolster what little self-esteem you're clinging to? I can't even begin to imagine what happened in your life to make you the kind of person that everybody hates." The usually confident surgical resident looks flustered and promptly drops the papers he's carrying, which is TV shorthand for "You're right, you discovered the hidden truth about my poor wasted soul".

While the idea that the narcissist has secret low self-esteem is popular, there is no evidence that the extroverted narcissist is insecure underneath- they like themselves just fine, and even more than the average person. Adults who score high on narcissism tests typically score high on self-esteem tests as well. The most common self-esteem tests include items such as "I feel I am a person of worth, at least on an equal basis with others," and "I feel that I have a number of good qualities." Someone who thought he was entitled to the best will easily agree with these statements. There is a small subset of "vulnerable narcissists" who do have occasional bouts of low self-esteem, but these individuals are rare and don't follow the most common patterns of the narcissist.

Psychological tests can measure self-esteem by asking respondents to pair keys for "me" and "not me" with positive and negative words that flash quickly across a computer screen. These tests are structured to measure response time in fractions of a second, which should reveal unconscious ideas or thoughts that a person is attempting to hide. People with high self-esteem find it easy to associate themselves with positive words like good and wonderful, but react much more slowly when trying to pair "me" with awful and wrong. Tests like these were used to ascertain whether narcissists were just saying that they were great, but secretly did not believe so. Several researchers have used this technique to discover how narcissists actually feel about themselves, and it turns out that narcissists think they're amazing people deep down inside. Their claims that they are awesome aren't just another fluffed up sales pitch; this perspective of personal greatness is one they truly believe.


Myth #3: Narcissists Really are Great/Better-Looking/Smarter

There is very little evidence that narcissists are actually any better on average than non-narcissists. Two studies found that narcissists didn't score any higher on objective IQ tests, and another found no correlation between narcissism and performance on a test of general knowledge. Studies on creativity are mixed, with one finding a positive correlation and another finding no relationship. Narcissists also aren't any better looking: across two studies, strangers who rated head shots found narcissists no more attractive than others, even though the narcissist thought they were better looking than average. Narcissists do know how to pick out a flattering picture of themselves. For example, the pictures that narcissists chose for their personal Web pages were rated as more attractive by observers. Overall narcissists believe that they are smarter and more beautiful than they actually are.


Myth #4: Some Narcissism is Healthy

Is some amount of narcissism healthy? The real question is "Healthy for whom?" Selfishness, for example, might allow you to get a bigger piece of dessert after dinner, but will hurt your longer-term relationships with your companions and might cost you a dinner invitation in the future.

If we are arguing that narcissism is bad, does this mean that belittling or disrespecting yourself is the right choice? The claim that ignoring your self-worth is the alternative to loving yourself is a false dichotomy. A small number of people do hate themselves and could use some self-admiration. However, consider that focusing on the self is only one of many possible routes to self-improvement, and enjoyment of the world. As alternatives consider your relationships with others, your work, or the beauty of the natural world. Think about the deepest joy you experience in life- it doesn't typically come from thinking about how great you are. Instead it comes from connecting with the world and getting away from yourself.

The idea that anti-social behavior is wrong should inform our stance on whether self-admiration is healthy. Narcissism at the expense of one's own performance is also not healthy. Narcissism that helps performance but does not hurt others, such as the confidence you might need before a big public performance, is the healthier aspect of narcissism, although there are probably other ways to get the same result without focusing so much on the self. Narcissism is by definition a focus on the self at the expense of others, and this almost always leads to problems for both the narcissist and everyone around them.


Myth #5: Narcissism is Just Physical Vanity

Although vanity is certainly one of the negative characteristics of the narcissists it is far from the only one. Narcissists are also materialisticly entitled, aggressive when insulted, and uninterested in emotional closeness.


Twenge and Campell reviewed a collection of articles where college students filled out the Narcissistic Personality Inventory between 1979 and 2006. Results from a total of 85 articles aggregated data for 16,000 college students. College students in the 2000s where significantly more narcissistic than Gen Xers and Babyboomers in the 1970s, '80s and '90s. The Baby Boomers, a generation famous for being self-absorbed, were outdone by their children. By 2006, two thirds of college students scored above the scale's original 1979-85 sample average. This represents a 30% increase in just two decades. One out of four recent college students answered the majority of questions in the narcissistic direction. To put this change in perspective it is as though in 20 years the average height of all men went up up by about an inch. You might not notice this immediately when say for example comparing yearbook photographs of a highschool football team from 1985 and 2005, but the measured change is unmistakable and indicates a shift in society for the worse.

Youth have unrealistically high expectations for themselves. In 2000, 50% of highschool students expected to attend law, medical, dental, or graduate school, double the expectations of students in the 1970s. However, the number of people who actually attain these degrees has not changed. In addition, more than two-thirds of high school students now say that they expect to be in the top 20% of performance in their jobs.

Dealing with narcissism in others can be quite difficult. People generally don't change unless they want to, and narcissism is a particularly unpleasant state of mind where a person generally believes that everything about themselves is really quite great. Spending a lot of time thinking about what is wrong with narcissists, or how a particular individual in your life that you believe is a narcissist is a huge pain doesn't help much. In Recovery meetings we don't talk about changing others but instead we talk about changing ourselves. We can look at the narcissist as a catalog of things to not do, and rather than accusing others of being narcissists we should instead ask, which of these behaviours have I allowed into my life, and which ones can I change.

Narcissistic attitudes have the potential to be extremely self destructive, in the chapter from MHTWT titled "Temper and Symptom- Passive Response and Active Reaction", Dr. Low examines (E) Peter (P), a man suffering from a large number of physical symptoms including uncontrollable anger, difficulty swallowing, concentrating, and uncomfortable bouts of belching. What disturbed Peter most was his lack of self-confidence and the inability to check his temper. In this interview Abraham Low is uncharacteristically blunt with Peter, he writes:

E: What seems to trouble you most is the fact that your self-confidence is reduced to a level in which you are no longer as cocky, argumentative, conceited and intellectually snobbish as you used to be. If my sharp wording displeases you I shall remind you of the pertness with which you used to voice your political opinions, the intolerance you used to display in your tiffs with friends, wife and co-workers, of the delight you took in out-arguing anybody who might engage in an exchange of views with you. As I see it, you do not suffer from any lack of self-confidence. You merely resent the fact that your former vanity and inflated sense of importance are now gone. You consider that a loss, thinking you have become a dish rag; I regard it as a gain, thinking you are on the way to develop a measure of humility. What interests me is your failure to curb your temper sufficiently. As long as you continue to indulge your temperamental habits your symptoms will persist. Eliminate your temper and you will do away with your symptoms.

P: I have tried the hardest to get rid of my temper and it seems to me I accomplished a good deal. At home I have few arguments, and in the shop I keep quiet most of the time. But of course I fly off the handle once in a while. And, good Lord, once I let myself go there are the palpitations and the confusion and some air-hunger and belching. Can't I ever be natural and human like others?

E: I am not at all concerned with your being natural and human. My sole objective is to rid you of your symptoms. You seem to think it is your natural and human privilege to exercise your temper. It is just as natural and human to eat steak. But if a man is suffering from a gastric upset he'd better relinquish his "natural and human right" to steak dinners. Are you willing to give up your temper for the sake of your health?

P: I guess I am willing. But this thing's got me licked. I try to be calm and I do pretty well most of the time. But if the boss is unreasonable and rides me the worst way I cannot hold back and tell him where to get off.

E: Give me an example of the manner in which the boss is unreasonable. Tell me what he does to "ride you the worst way."

P: The other day when I came to the shop a tool was missing. I asked the boss whether he had seen it and he said, "You lost it and you will have to find it." That just burned me up. I came back with a saucy remark and he laughed out loud. That dirty laugh made me boil. I let loose and gave him a mouthful. It didn't take a minute and I had my belching and it took me hours to get rid of it.

E: From what I know about you it seems to me that this example is representative. It represents your customary habit of reacting to minor frustrations. You asked a question, and the boss returned a gruff answer. Instantly you became irritated to the point of "burning up." The next link in the chain of events was that you came back with a "saucy" remark. The boss, refusing to become temperamental, laughed and made your blood "boil." The final result was that you belched for hours. You will realize that what "burned" and "boiled" was your temper. You know, however, that temper will neither burn nor boil unless you form the idea that you have been wronged. From this we conclude that prior to releasing your temper you thought or decided that the boss was wrong and you were right. It was this temperamental thought in your brain that touched off the temperamental commotion in your body. This again led to the "saucy" remark and ultimately to the sustained fit of belching. Let me repeat: there was (1) the temperamental thought, (2) the temperamental commotion, (3) the "saucy" remark, (4) the belching. You will understand that the thought "he is wrong and I am right" can be rejected, suppressed or dropped. You will also understand that your "saucy" remark could have been checked. In other words in this fourfold series of incidents, two lent themselves readily for control. You could have rejected the thought of being wronged by the boss and could have prevented your muscles of speech from voicing the "saucy" remark.

When we read this chapter in our most recent meeting people laughed out loud at Low's initial remarks to Peter. This interview is quite unusual for Dr. Low, while often firm in his discussions with his patients he is rarely this direct and harsh. Peter is caught in a difficult place, where the recommended cure is for him to find some humility, and he feels that by being humble he has become a "dishrag".

Peter, in many ways, is suffering from some of the characteristics of the narcissist. He is self absorbed, abusive with his family and with his boss and coworkers, and the suggestion that he should be more patient, less argumentative, and less full-of-himself seems to him to be a terrible idea. Yet Peter's symptoms are extremely severe, the stress that Peter puts himself though by constantly arguing with his boss and his family cause him to belch uncontrollably, resulted in an emergency trip to the hospital after he feared he would physically collapse, and have left him a worried wreck.

Dealing with someone like Peter is exceptionally difficult. In this excerpt where Peter is soliciting Dr. Low's help even Dr. Low seems to feel frustrated as he tries to convince Peter that his troubles are rooted in selfishness. Twenge and Campbell note that narcissists are extremely difficult to change, and rarely do they show up for treatment. Usually what happens instead is those hurt around them are the ones who end up in distress. If you recognize a full blown narcissist in your life the recommendation is to be extremely cautious if you must deal with them, and get away from them if you can. If you recognize these behaviours in your own life these are things that you can and should change. You may feel like Peter, that giving up your old habits is tantamount to becoming a dishrag, however try to recognize this as a growing pain. Change is difficult, and letting go of selfishness is not the same as letting go of self-respect.

When I read The Narcissist Epidemic it made me rethink the notion that self-esteem was extremely important and my lack of it might be the root of my troubles. The conclusion offered by Twenge and Campbell is that while negative perceptions of the self can be a problem in some limited circumstances they are not nearly as problematic as over-confidence, and an unrealistic over-valuation of the self. Humility may seem like an old-fashioned value, and according to the authors of The Narcissism Epidemic it has largely fallen out of favor, but they also present compelling evidence through a broad survey of scientific papers that focusing too much on the self provides no advantage, and if done at the expense of others, can be detrimental.

Recovery meetings are organized not by professionals, but by volunteers experienced in the method. We work together to continue to learn good habits and discuss strategies for managing our fears and anger. One of our basic tools is the reminder to be "Group Minded", or consider the impact of your words and actions on everyone around you. While the narcissist fails to consider anyone but themself, there are also those that fall into the opposite trap, and ignore their own needs and do whatever is asked of them. Striking a balance between your own self-interest and the interests of others is important, and is one of the core values that we discuss at Recovery meetings.


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How to Deal with Difficult People

Sarcasm, Humour and Ambiguity

About Recovery Hamilton

Sunday, November 12, 2017

How to Deal with Difficult People

Everybody has difficult people in their lives. Family members can present the toughest challenges. For some it is older parents stuck in unpleasant habits where they endlessly condescend and push buttons from your childhood, for others it is a sibling or old friend who only calls when they want or need something. For immediate family members who live in the same home there is no easy escape. Bad bosses or bad co-workers can be equally stressful and hard to get away from, especially if they can contact you at home or on the weekends.

Many of these conflicts revolve around power struggles, and button pushing. People who you know and love understand your buttons, and will press them when they feel they need something that they think you may be unwilling to give. In contrast there are sadistic individuals who push buttons for the simple pleasure of exercising control. These people aren't confused about what they are doing. They know how to hurt others and they do it for personal gain, ego gratification, and sometimes for no reason at all, simply because it's how they operate in the world. Regardless of whether you are dealing with someone who is accidentally causing collateral damage with their careless remarks, or someone who is actually out to intentionally hurt you may make little difference. If you are already struggling with your own anxiety, worry, and insecurities these exchanges can be particularly difficult.


What can you do to change these people? In a few words, usually next-to-nothing. As unpleasant as this is going to sound, when dealing with someone difficult the first thing to focus on is not their behavior but your own behavior. My biggest misconception over the years was believing that I ought to be able to think of the right thing to say or do to make these people stop doing whatever it is that they are doing that bothers me so much. I've always been looking for that particular "truth bomb", the thing that will open their eyes to the shady behavior that they exhibit and make them treat me with respect. Looking for that bomb is like looking for the holy grail, a winning lottery ticket or a unicorn, it might be out there but it isn't a reliable answer to the everyday conflicts that we get into.

This drama is an old movie trope, the guy who goes home for that bad family Thanksgiving / Christmas / birthday dinner, and in response to the unpleasant lecherous-uncle / unforgiving-mother / angry-step-father / smugly-successful-yuppie-sibling our hero says something that makes everybody's jaw drop. The family realizes that they've misjudged that guy all these years, and in their stunned silence and new awareness of how badly they've behaved all their lives the hero of this story walks off triumphantly into the night satisfied that their life and relationships have finally changed. I've never seen this happen in real life, and as satisfying as it seems in the movies, in practice it just isn't how things ever go. The Will Ferrell comedy "Step Brothers" includes multiple truth bomb dropping confrontations like this. They are hilarious, and brilliantly executed in this comedy about a dysfunctional family that struggles to deal with two men who refuse to grow up. These situations aren't a reflection of reality, they are only something that we wish would happen.

One of the biggest troubles with this bomb dropping fantasy for me is that I've wasted day upon day rehearsing the "bomb" for a variety of situations, and then when confronted by the difficult person, my bomb fizzled. Either the setup never presented itself, or if I did drop my bomb the difficult person had their own collection of bombs, darts, snarky responses, and Teflon coated shields. The enlightenment and chagrin that I'd hopped to create never materialized. Instead of an easy victory, yet another ugly squabble ensued leaving me feeling as defeated and drained as before. On top of defeat there is the extra unpleasantness of the endless rumination over the difficult conversation, and rethinking what I should have said and could have done. This after-the-fact mental grind about "next time" is extremely destructive, and is what keeps this particular vicious cycle going and without resolution.

In Recovery we make a distinction between the inner environment and the outer environment. The inner environment includes your thoughts, feelings and sensations, and of these aspects we only have marginal control over our thoughts. The outer environment includes all of the things that you cannot easily control like the weather, the economy, the next election, and other people. Spending effort trying to control other people leads to frustration and disappointment. The measure of control that you are able to establish is either usually very slight, or requires such an enormous effort that it becomes a full time occupation (think about a totalitarian state like 1940s Nazi Germany or modern day North Korea and what they have done to keep people under control). We recommend that you focus on the things you can control, this includes what you think, what you say, and what you do.

Conflicts with family often revolve around trivial notions of right and wrong. Letting this go can be a first step towards dealing with a difficult person. In the chapter titled "Temper, Symptom and Insight" from MHTWT Frank describes a conflict with his mother as follows:

Frank R.: I can give an example that shows two sides of the story, that is, the difference in the results whether temper is or is not controlled. The other night I walked home with Harriette and met my mother on the street. She had a letter to mail. I offered to let Harriette mail it so I could carry the bundles. But mother asked me to mail it. As usual, she had to have her own way. I lost my temper and grabbed Harriette and said, "Let's go," leaving mother to mail the letter. After that I was pretty angry for a short while but it was all over soon. In former years I would have tried to justify myself; I would have been furious about the domineering ways of my mother, but this time I didn't do anything of the kind. The incident was closed as far as I was concerned. Later on when mother came home I spoke to her and she did not answer. A year ago or so I would have got angry again but that evening I simply kept quiet. At supper mother hardly ate anything and after the meal was over she cried. Of course, I didn't like that but since as you all know there is a deadlock between us I couldn't do anything about it. As I said before there is a difference in results between now and before. Before I had my Recovery training the deadlock led to endless quarrels because neither of us would give in. Now I keep quiet and while the deadlock persists there is no argument. More than that, in former days I would have been angry and stayed angry for a long time and incidentally I wouldn't have felt like eating, either, but on this particular night I ate as usual.

Annette: In other words, both you and your mother would have staged a contest as to who would starve most and say least. Well, you say that this time you faced the fact that the manner in which you acted might have been wrong and temperamental. You refused to prove that you were right. That is of course the best way for cutting short arguments. 

I always feel sympathy for Frank when we discuss this chapter in meetings. His solution to not engage in conflict with his mother reduces the stress that he experiences, and is an improvement on his past where he would have argued with his mother instead of eating his dinner, but it isn't a total resolution to the issue. The deadlock that he finds himself in seems really unpleasant. The important thing to recognize here is that Frank can't change his mother and since he still lives with her he can't easily walk away from the relationship. What he is accomplishing is improving his situation by recognizing that conflicts about incidental requests like delivering a letter are not worth staging an argument over. While his mother might resort to a guilt trip by crying over the disagreement and refusing to eat her dinner, Frank doesn't escalate the situation any further. By refusing to buy into the conflict his mother sets up he takes an important step towards improving his mental health.

I recently started reading a book called "Talking to Crazy" by Dr. Mark Goulston. This book presents a collection of common scenarios and simple strategies for dealing with difficult people. Goulston is a practicing therapist and in the first chapter he gives a list of the sort of difficult people he has had to deal with during his career including; heroine addicts, hallucinating schizophrenics, a Britney Spears stalker, and someone who called him from jail in the Dominican Republic saying he was there to start a revolution. Goulston advocates a number of strategies for dealing with extremely difficult people, although he dedicates the first quarter of his book to dealing with your own issues. When you talk to difficult people, any vulnerabilities that you have become liabilities.

He presents a simplified structure of the mind where he breaks it into three basic components, the higher reasoning brain, the emotional relationship oriented midbrain, and the primitive feeling brain, sometimes called the reptilian or lizard brain. This breakdown, while a helpful analogy, is also based on real biology. Last weeks article on the "Biology of Depression's Vicious Cycle" discusses how recent researchers have used fMRI images to observe the activity in the prefrontal cortex, or the reasoning part of the brain and the activity in the amygdala, or reptilian brain to understand how depression changes brain activity. In a reasonable individual Goulston argues that these three components are in alignment,  usually with the rational part of the brain making decisions based on information from the other parts. When dealing with someone who is irrational or aggressive, often one of the other components has taken over.

A strategy that difficult people sometimes use is the "amygdala hijack", where they shout and behave badly, or demand sympathy attempting to get their target's amygdala, or primitive reptilian brain to take over. Once the target is in an upset state, and either frightened or shouting back, what in Recovery we would call being in temper, the instigator often gains a measure of control. Some people are very used to living in a state of hyperactive fear or aggression and when they drive other people into that same state they obtain a maneuvering advantage by being in familiar territory. After many years of practice they know some tricks for getting what they want, and by disabling your rational side they are able to go for a win.

Both Goulston and Low give the same recommendation, maintain poise and control, and resist the urge to respond with unreasonable or threatening tactics. In Recovery we say "Temper begets Temper, Peace begets Peace", this is one of the tools we use to explicitly acknowledge that when you meet someone else's anger with your own you simply perpetuate the conflict, you don't really resolve anything. If instead you remain calm, or at least present yourself in a calm and reasonable way and don't allow your primitive reptilian brain to take over you will have the opportunity to deal appropriately with the situation. This isn't easy. Being shouted at can feel like being hit with a hammer and your instinct will be to hit back with the same level of force to make the attack stop, however, in this scenario your instincts won't help.

In Recovery we are not suggesting that you should become a dishrag. Responding reasonably to an unreasonable assault doesn't mean rolling over or giving up. When we talk about not arguing about trivialities we don't mean to say that you should always give in, we mean don't get into meaningless fights, instead choose your responses carefully. You can always make very reasonable choices, like recognizing that someone is baiting you into a nonsensical conflict, or recognizing that someone is trying to shut down your reasoning faculties by shouting at you. Always stick up for yourself, but remain smart and stay in control. Being civilized doesn't mean you should wimp out, it means keeping your cool and making a choice rather than responding impulsively.

The most basic thing to evaluate after the umpteenth conflict with an unreasonable person is whether you need to keep this relationship at all. Many people hold on to old friends out of loyalty, and stay in contact with unpleasant family members because that is just "what you do". If these relationships are particularly fraught it is worth considering whether you can limit your time with these people, or possibly even remove them from your life entirely. Limiting your involvement can take the form of attending fewer family dinners, being at those dinners for shorter periods of time, or skipping them all together if the scenario is sufficiently toxic. Goulston provides the following checklist to help you make this decision about whether to keep this person in your life or not:

  • Can you rely on this person for emotional or psychological support, or is the person distant or even abusive?
  • Can you rely on this person for practical help, or does the person let you down whenever you need assistance?
  • Does the person accept responsibility for his actions or blame others?
  • Is the person reliable or unreliable?
  • Is the person self-reliant or needy?
  • What should this person expect from you, and what are you actually giving?

Based on this list ask yourself whether this relationship is worth saving, or whether you should cut this person out of your life. Try to be fair in your assessment and consider your whole history with the person. Sometimes you will owe this person loyalty because you are grateful for things they did in the past. With others you will find you are just sticking with an irrational person because you don't want to feel like the bad guy. If you are concerned about the guilt that you would feel if you left this person and this guilt is the only reason you are staying with them, this is a very strong signal that you need to disconnect.

Keep in mind that there are degrees to which you can reduce your involvement with some people. You can respond to fewer invitations or requests for favours, you can limit the total amount of time you spend with this person, or change the type of time you spend with them. For example you can engage with them in group settings instead of one-on-one settings, or you can reduce your relationship to e-mails and telephone calls rather than visits. Who knows, the person might change on their own, but don't bank on that eventuality.

In Recovery we emphasize trying to find civilized solutions to conflicts. This means not shouting back when shouted at, but instead speaking reasonably to people regardless of their conduct and if necessary walking away from someone who constantly shouts at you and won't relent. It is always fair to try to engage with people who are having a hard time. Sometimes we are the ones who fail to control our urge to shout, blame or sullenly withdraw. I'm very grateful to everyone who has patiently talked me down when in this state of mind. If you can engage with someone on a rational level, despite the crying, shouting, and guilt tripping, that is ideal. However, not everyone has your best interests at heart, and it's important to keep in mind that while you can change how you respond, and you have some influence over other people, you can't control them. If when you improve your behavior they don't improve their's, you may need to accept that there is nothing that can be done, and you may need to choose to move on.


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Sunday, November 5, 2017

The Biology of Depression's Vicious Cycle

My experience of depression was that of being locked in a trap of bad feelings and bad ideas. Everybody has bad days some of the time, and when not depressed, I can spring back from a bad day with relative ease. Sometimes watching a movie, or hanging out with some of my friends, or even just going for a walk is enough to reset my mind. When depressed my mind becomes like an angry dog gnawing on a dried out old bone, refusing to let go, and insisting on grinding away despite being bored, tired, and disinterested. No distraction, regardless of how positive, could pull my internal mental gaze away from staring into the abysmal gloom of a dark and hopeless future, or worrying about my worthless and maladjusted past.

In Recovery we call this a vicious cycle. The vicious cycle of depression intensifies and perpetuates symptoms of the illness. This frame of mind is more than just an unhappy disposition. Depressed people often have difficulty feeling joy, and it is this dogged focus on the unpleasant, the doom and gloom of the world, that in many ways defines depression. Being stuck in repetitive thought patterns is often called rumination, and is a symptom of both anxiety and depression.

Depression is an ailment of mood, where one persistently feels that everything is worthless, and also an illness of motivation, where doing something about the perceived problems with your life is exceptionally difficult and painful. Sometimes I could see clearly what ought to be done, but the intense feeling of lifelessness that pervaded my daily experience made taking action nearly impossible. It wasn't just that I was thinking about negative things all the time, it was like not being able to think about anything else, wanting to think about negative things and having no interest beyond the bleak and the dismal. My mind felt infected, and bent on consuming itself.

Dr. Aaron T. Beck

Dr. Aaron T. Beck introduced the cognitive model of depression over 40 years ago. While Abraham Low's peer support methods that define Recovery meetings predate Beck's work, Beck defined Cognitive Therapy in rigorous scientific terms and popularized the method among therapists. Recent work by Beck and his associates examines the details of rumination, the anatomy of the brain structures associated with rumination, and the behaviors that cause depressed people to get stuck in negative thinking patterns and destructive feedback loops.

The following is a summary of an article titled "Neural mechanisms of the cognitive model of depression" by Beck and his colleagues.

According to Beck’s cognitive model of depression internally stored representations of events, ideas and experiences are activated by internal or external events and then influence how incoming information is processed. 

These representations determine how an individual interprets their experiences in a given context. Adverse events that occur early in life might lead to the development of depressive ideas, which are characterized by negative self beliefs. Depressive ideas can be activated by subsequent stressors that reflect underlying values (for example, a job loss may be devastating for someone who equates full time employment with self worth).

Unrealistic values which create a vulnerability for depression, once activated by an event, can change information processing related to ideas about the self, the personal world and the future. This group of concepts is referred to by Beck as the negative cognitive triad. Understanding this triad is the basis of Beck's cognitive therapy method.

Once a depressive episode begins, attention, interpretation and memory are effected. Negative and pessimistic processing of one’s self and context become pervasive, including interpretations, evaluations and appraisals. As a result the individual with depression develops dysfunctional attitudes whereby he or she views themself as defective and day-to-day life as rife with struggle, and assumes that their current difficulties or suffering will continue indefinitely.

The activation of these dysfunctional attitudes increases the likelihood that the depressed person will choose negative situations and filter out positive information. This process increases awareness for depressive elements in the environment and can decrease the positive experiences of a pleasing event, a phenomenon often referred to as a positive blockade. Similarly, there is strong evidence for memory biases in depression. In particular, individuals with depression tend to exhibit preferences for remembering negative experiences over positive ones.

Recent research has suggested that specific impairments in memory and attention are related to inhibitory deficits or, in other words, the inability to disengage from negative stimulation. Several theorists have suggested that inhibitory deficits are manifested clinically as rumination. Depressive rumination, or the tendency to think repetitively about the causes and consequences of negative experiences, has been associated with the onset, deteriorating course, chronicity and duration of depression. Specific biases in attention and memory result from inhibitory deficits, which perpetuates negative thoughts about the self, the world and the future. This process creates a feedback loop within the cognitive system that serves to initiate and maintain an episode of depression.

The inability to allocate attention to appropriate emotional cues is central to the cognitive model. For individuals without mood disturbance, attention is generally biased towards positive situations and events. However, individuals with clinical depression have no selective attention towards angry, happy or neutral input, and instead show a bias for sad stimulation. The inability to disengage from negative events, ideas and activities is thought to exacerbate symptoms of unease and dissatisfaction with the world. 

There is evidence that people with depression show increased attention for negative stimuli and decreased attention for positive stimuli compared with non-depressed individuals. In contrast healthy individuals require greater cognitive effort to divert attention away from positive stimuli, while individuals with depression require greater cognitive effort to divert attention away from negative stimuli. 


http://brainpictures.org/Depression-Brain-Pictures.php

When individuals with depression process negative input, they show brain activity that is more intense (by up to 70%) and longer lasting (up to three times as long) than in healthy people, even when an emotional task is immediately followed by a nonemotional task. Recent studies indicate that this pattern of response is automatic and exists even if the emotional content of the task is masked to the conscious mind through a subliminal presentation. Depressed individuals will also process negative events faster than those who are not depressed. This change in reactivity in individuals with depression persists even after the adverse stimulation is removed.


It seems that individuals with untreated depression are not only more likely to attend to negative thoughts and experiences than healthy individuals but experience a stronger and longer lasting neural response to these events. The perception of negative information may persist as a result of reduced cognitive control.

Measurable anatomical abnormalities in the prefrontal cortext, which is the part of the brain responsible for executive functions such as working memory, cognitive flexibility, planning, inhibition and abstract reasoning, can be found in some individuals with depression. Research indicates that negative thoughts and experiences have a bigger impact on individuals with depression compared with healthy people. In addition, depressed individuals generally experience a positive blockade, in the sense that they have decreased capacity to process positive emotion and that positive experiences seem to be more difficult to absorb. For example, processing of happy faces involves activation of a particular part of the brain in healthy individuals, but activity in this area decreases measurably as depressive symptoms increase.

Unlike the experience of negative emotion, which is common to mood and anxiety disorders, decreased positive emotion is thought to be a distinctive feature of depression. In healthy individuals, the ability to experience and maintain a positive attitude is closely associated with brain systems that mediate reward and motivation. Decreased response to reward in individuals with depression is consistent with functional MRI results which compare brain activity in healthy individuals with those that are depressed.

In individuals with depression, reduced responses to rewards suggests that rewarding properties associated with an event may not be accurately perceived. As a result, rewarding situations may fail to trigger reinforcement mechanisms, which could impair the ability of individuals with depression to pursue rewarding behaviours. 

Biased memory is closely related to biased attention and processing, in that increased awareness for negative stimuli influences the probability that negative information will be encoded and later recalled. This means that the same mechanisms that influence a depressed person in such a way that they pay attention to negative ideas and events will also create an inclination for them to store more negative memories than positive ones. Attempting to recall emotionally charged autobiographical memories yields very different responses in individuals with depression versus healthy individuals. One interpretation is that individuals with depression require greater cognitive effort to recall happy personal memories, whereas recall of negative memories requires less mental effort.

Dysfunctional attitudes play a central part in the cognitive model of depression. Here, the individual forms firm beliefs or representations about themself, their environment or their future that directly relate to their own self worth. Although relatively few studies have examined the networks involved with dysfunctional attitudes, existing research has identified several areas that are associated with these maladaptive beliefs. During negative self-referential tasks, individuals with depression show an intensity of brain activity that is correlated with depression symptom severity.

The amygdala, which is located near the bottom of the cognitive hierarchy, has a primary role in memory, emotional processing and decision making. In depressed individuals the amygdala is more active than in those who are not depressed when they recall negative events, indicating that a stronger than average emotional experience is correlated with depression and negative memories. The prefrontal cortex, which is located near the top of the cognitive hierarchy, is thought to be the key region for internal representation of self. In fMRI studies, this area shows the highest baseline activation when the subject is not actively involved in a task, suggesting that the prefrontal cortex may respond to self-focused stimuli. This area shows a great deal of activity in depressed individuals when they try to focus on positive events, indicating that this activity requires more cognitive effort than average, and is difficult for people suffering from depression.

The neurobiological mechanisms that underlie cognitive biases in depression seem to be influenced by two key processes: 1) low level processes and primitive feelings that tend to initiate negative cognitive bias in depressed individuals and 2) attenuated cognitive control- or a reduction in the ability to manage basic emotions, which allows the bias to persist.


http://brainpictures.org/Depression-Brain-Pictures.php

These processes are observable and measurable in depressed individuals with modern brain imaging techniques. Research done with fMRI scans illustrate the activity of the lower and higher brain functions as depressed individuals respond to events. This research has been used to guide certain treatment paths, both medical, and talk therapy based.   

Traditional Cognitive Behavioural Therapy (CBT) is used to target the elements of Beck’s model, particularly dysfunctional attitudes, using direct cognitive interventions such as thought records and guided discovery. Using CBT and other techniques to reduce cognitive biases aims to undermine patients’ perceived accuracy of their negative values and ideas.

While this theory is interesting, and from a scientific perspective tells us details about the mechanisms of rumination and the vicious cycle, and how these phenomena can be observed in the brain, what can we practically do with this? It is helpful for some people to have confirmation of their experience, that their physical feelings of being stuck are externally measurable and in some sense real. Whether we believe that brain structures influence how we think, or that how we think can change the structure of our brain isn't so much the point here, rather it is the case that these phenomena are consistently observed together. These observations validate theories about depression, and help to explain how talk therapies work.

When you feel depressed, there is a measurable failure and biological dysfunction of your brain at work, changing your behaviour and your thoughts can address that dysfunction, although it is difficult. In an interview with a patient (P) in the chapter "Vicious Cycle, Vitalizing Cycle" from MHTWT, Abraham Low, the examiner (E), records the following:

E: How is it, I shall ask, that your thought pulse shows life and vigor during this interview and loses its vitality in other groups? 

P:I still think it is the vicious cycle that does that.

E: I told you I am ready to accept the explanation. But it will have to be qualified. There are many types and degrees of vicious cycles. One of them is that of fear, another of anger. These are the most common varieties. If yours were that of fear the vicious cycle would fan it into a panic. If it were that of anger it would be raised to the pitch of rage. I have observed you in the company of other people and you gave no evidence of being rocked by either panic or rage. Your face was smooth, perhaps even blank, and its muscles gave little evidence of lively expression. You sat motionless, staring into space. You give this a different wording when you say that your brain does not think and your speech muscles do not move. They are not lifeless by any means, but you feel that life has gone out of them. The brain feels unable to think, and the muscles unable to act. The more helpless the brain the more limp are the muscles; the more limp the muscles the more helpless is the brain. This is the vicious cycle of helplessness. How is it, I shall ask again, that you are able to shake off this sense of helplessness when you are interviewed here in front of a large crowd? 

P: I don't know exactly but the nearest I can think of as an explanation is that I don't feel cramped here as I feel in groups on the outside. 

E: That does not explain a great deal. It seems to me I shall have to do the explaining. We spoke of a vicious cycle. That means that some sort of circular movement is set up between the brain cells and the muscles. In this cycle the brain acts on the muscles, and the muscles act on the brain. The two influence one another. The cycle begins its destructive work before you arrive at the particular gathering. For hours and perhaps for days you have anticipated that your brain will be paralyzed and helpless. On the way to the social function which you are to attend the "freezing" process begins and when you reach your destination it has deepened into what you call a blank. The brain feels lifeless and dispatches impulses to the muscles not to stir, not to move. In this manner, the helplessness of the brain communicates itself to the muscles and the vicious cycle is set afoot. I told you that brain and muscles influence one another in this cycle or circular movement. Since they interact or act on one another it ought to be clear to you that if you cause the one to move the other will follow suit. 

To state it differently: make the one move and the other will perforce join the movement. You may not be able to get the brain moving. But you certainly can do that with muscles. Command your speech muscles to act, and the brain will instantly realize that its theory of helplessness is a myth, a fiction, an untruth. The more vigorously your muscles will move, the less will the brain be able to believe that it is helpless.

...

The movement of the muscles convinced the brain that speaking is possible. And when the brain witnessed the living, vital performance of the muscles it acquired a new vitality itself and lost its lifelessness. The more forceful was the action of the muscles the more vitalized became the brain; the more vital the brain the more forceful the muscles. By commanding your muscles to move you had thus transformed the vicious cycle of helplessness into the vitalizing cycle of self-confidence.

In recent research into the brain activity of depressed individuals we can observe the often reported experience of the preference for negative stimulation, and the lack of response to positive stimulation. As a person who is depressed or is prone to depression this means that you need to be especially aware of why you are choosing to do certain things. It is important to recognize that just because you don't feel the same sense of accomplishment from doing something positive that you used to (like cleaning your room or visiting with you family), that doesn't mean you should give up these positive activities. You also need to be aware that you will have a tendency to focus on the negative events and memories in your life, and these will seem more vivid than positive memories. This isn't reality, it is your illness speaking to you, and it is a change that you can either reinforce by continuing to focus on negative ideas and activities, or with effort undo.

Dealing with depression is difficult. Depression is characterized by the vicious cycle; it is an illness of motivation that has an impact on your memory, your preferences, and your general impressions of the world and how you experience it. These impressions are not permanent changes in your life they are rather the paper tigers of mental illness. Being unwell, depressed individuals will often want to be inactive or spend time resting. Depression, however, is not an illness like the flue, where rest will provide a curative measure. Instead inactivity will intensify depression and lead us further into self destructive predicaments, this is the vicious cycle that keeps people locked in a state of illness.

At Recovery meetings we understand these difficulties and we can help encourage you to have better habits and make active changes to your life. Many of us have suffered through vicious cycles, unproductive ruminations and dealt with our tendencies to complain and endlessly focus on our own troubles. These are problems that can be addressed one at a time, and are part of what we talk about each week. New attendees are always welcome, we can provide tools and support. Join us on Tuesdays at 7:30, at Binkley United Church in Hamilton, or at one of our other meetings.


More Information

Does Depression have a Physical Cause?

The Complaining Habit

Feelings are not Facts

Sunday, October 29, 2017

Mental Health Myths, Inkblot Tests and Electro-Shock Therapy

Stigma associated with mental illness can be a serious deterrent that prevents individuals from seeking help. While it is estimated that as many as 1 in 5 of the North American population suffers from a diagnosable mental health issue, 80% of those who are suffering will not seek assistance. Some of this stigma comes from popular ideas surrounding psychiatric treatment, a general confusion about what talk therapy is, lack of clarity regarding the efficacy of the various anti-depressant drugs and other medical treatments available today, and a general misunderstanding of what mental illness entails.

Mental illness is frightening for some people in a way that physical ailments are not. While people are of course afraid of being hurt in a car accident for example, the shame associated with mental illness has no analogue in physical injuries. We sometimes associate mental illness with a moral failing, a bad background, or a lack of will power, and these reactions are simply unfair and unkind. We rarely blame someone who has broken a bone in a sporting accident on the weakness of their personality, or worry that this injury indicates that the person is no longer trustworthy.

These fears have three principal sources, 1) the general lack of understanding surrounding the symptoms of mental illness, 2) the long and complex history of psychiatry, and 3) the cultural myths around the behavior and treatment of the mentally ill.

When I first struggled with depression I went to see several different university counsellors. If you are a university student you should be aware that many campuses offer mental health counselling services to students free of charge. I was able to see social workers at various times during my studies who were happy to meet with me on a semi-regular basis. The counsellors that I saw essentially just listened to what I had to say, some offered more advice than others. My confusion and fear about what was happening to me left me unable to ask direct and clear questions. While I think these counsellors tried to help and were reasonable and decent people, given that my initial symptoms were rather vague, their advice wasn't very specific.

Rorschach Inkblot Image

Free association, and its visual relatives, the Rorschach inkblot test, and the Thematic Apperception test, are all rooted in very early notions of diagnosing psychiatric patients. These methods are grouped under the title of projective techniques, and many people are familiar with them in at least a theatrical presentation of psychiatry. Everything I knew about psychiatry when in university I had learned from movies and television (I was majoring in mathematics and computers at the time), since what I saw on TV was usually some form of free association diagnosis, I thought that this was what I was getting from university counsellors.

The practice of letting a patient explain their worries and concerns, and talk about their past with little guidance from the therapist originates with Freud. In free association an individual lies on a couch, sometimes with the therapist seated behind them out of view, and says whatever comes to mind. In this model it is the therapist's job to help the client connect ideas and feelings that he or she was not aware of. Freud also analyzed dreams in this way. He developed this method in part because at the time hypnosis was being used as a therapeutic method to treat mental illness, and hypnosis did not always work. Freud found that many patients could not be hypnotized, and so he developed free association as a more general technique to explore the psyche of his patients. While some therapists still use a variation of this Freudian method, it is rarely used in this classical form today. In Mental Health through Will-Training Dr. Abraham Low has several very critical things to say about classical psychoanalysis, specifically that it is a very long and expensive process.

There is a recent BBC documentary discussing Signumd Freud's work and life presented by Bethany Hughes. While she credits Freud with inventing modern psychoanalysis she is also careful to point out that there were numerous flaws in how he treated his patients. She makes clear that today most people question the effectiveness of his methodologies and the utility of his basic theories as part of treatment.

In the early 1900s Herman Rorschach experimented with inkblots. He was interested in the sensory processing of abstract images by his patients, and used the images as stimulus for a test similar to the free association method used by Freud. For Rorschach, the content of what was seen in the inkblot was not as interesting as the elements used, for example whether the person saw a whole image, or whether they focused on small details in the blot. Rorschach published a small collection of plates in a book on the subject in 1921. He died shortly thereafter. After Rorschach's death various clinicians adopted the method and used it as a part of their practice. Scoring the Rorschach test is a complicated process that continues to be the focus of scientific debate. While the Rorschach inkblot test has a long history of use, and there have been recent attempts to update and standardize the test, researchers remain critical of its value.

The Thematic Apperception test (TAT) is composed of 30 black-and-white drawings of various scenes and people. Typically an individual is shown 20 cards, one at a time, and asked to create a story about what is going on in the picture. The idea is that by observing the character and themes of an individual's response that it is possible to gain insight into their thoughts. For example, if an individual often talks about one person leaving the other, the therapist might ask whether abandonment is an issue. The TAT lacks scientific evidence that might make it useful as part of developing a diagnosis.

Thematic Apperception Test Image

While some professionals see the value in these projective techniques in terms of their ability to test how an individual responds to ambiguous stimuli, the major disadvantages of these methods center on questions of validity and the test's ability to tell us anything specific.

Because of the visual quality, mysterious character and history of these tests they are often featured in movies and television programs. Before meeting any counsellors or therapists I believed that psychiatry was about lying on a couch while talking about my childhood, my feelings and that as I responded to strange images I expected a therapist to write down lengthy notes. After some time the therapist would tell me something dramatic and enlightening about myself, and this would be my road to a cure. Despite meeting many psychiatrists and counsellors I've never had any of these experiences. Psychiatry, insanity, mental institutions, and treatments for the depressed or suicidal are a common trope of films and literature, and there was a time when this was all I knew about the treatment of mental health. Some of these films are great, truly terrifying, and fantastically suspenseful, but not entirely realistic or helpful for those who have an actual mental illness.


Recently I watched the "Mind-Hunter" series on NetFlix that chronicles the development of the early behavioural sciences unit at the FBI and focuses on the personal difficulties that the investigators have as they learn about the unusual behaviour of serial killers through one-on-one interviews. Another film I enjoyed recently was "A Cure for Wellness", which tells the story of an executive who is sent for an unusual therapy in the Swiss Alps, and learns that once patients enter this idyllic sanatorium they are reluctant to leave. In a "Clockwork Orange" drug based conditioning is used to modify the violent behaviour of Alex, a young gang leader. After a failed suicide attempt Alex takes a version of the TAT test to measure the damage that resulted from his behavior modification. In "Harold and Maude", an affluent teenage boy fascinated with suicide falls in love with Maude, a 79 year old survivor of a concentration camp. Harold's therapist accuses him of sexual perversion, while Maude teaches him about the joys of life. The "Hannibal" TV series as well as its original source material "The Silence of the Lambs" present variations of the fantastical Dr. Leckter, who uses his knowledge of the human psyche as a weapon. "12 Monkeys", staring Bruce Willis and Brad Pitt, is another great example of thriller science fiction that features macabre scenes set in psychiatric wards where the stresses of time travel cause Willis' character to be unsure about reality. The contemporaneous "Fight Club", starring Brad Pitt and Ed Norton has an entire sub-narrative devoted to group therapy meetings, and formed my initial expectation of what I would find at Recovery meetings. These expectations where entirely inaccurate as I learned when I first attended a meeting.

The most famous story featuring a psychiatric ward is perhaps "One Flew Over the Cuckoos Nest". The film version is an adaptation of a 1962 novel by Ken Kesey of the same title and is considered by many to be one of the great films of the 20th Century. Wikipedia summarizes the plot thusly:

In 1963 Oregon, recidivist criminal Randle McMurphy is moved to a mental institution after serving a short sentence on a prison farm for statutory rape of a 15-year-old. Though not actually mentally ill, McMurphy hopes to avoid hard labor and serve the rest of his sentence in a relaxed environment. Upon arriving at the hospital, he finds the ward run by the steely, strict Nurse Ratched, who subtly suppresses the actions of her patients through a passive-aggressive routine, intimidating the patients.

I think of Nurse Ratched as the ultimate evil movie villain. In rewatching this film it is Louise Fletcher's performance in the role of Ratched, the sadistic psychiatric head nurse who employs shock therapy to control patients, which I found both brilliant and riveting. Her endlessly cool control of the ward and her conflict with Jack Nicholson's character McMurphy as he escalates his disruptive behavior are what make this film a masterpiece.

I believe that it is important to be able to enjoy media and remain critical of it at the same time. Having recommended all these films as great examples of modern television and cinema featuring scenes of psychiatric wards and people suffering from mental illness, I think it is important to point out that while these films borrow from the truth, they don't tell an accurate story about either mental illness or its treatment. In all of these examples the mythology of psychoanalysis and its associated treatments are used to create suspenseful and intelligent narratives based on the truth, but not necessarily fully representative of the truth.

These good stories create real stigma for people seeking mental health treatment, and they also create confusion about what one might reasonably expect as treatment. Electro-shock therapy or as it is more formally known, Electro Convulsive Therapy (ECT) was used widely in the 1940s and 1950s before anti-depressants drugs were developed. The treatment is still available today in a somewhat modified form. The modern version is usually coupled with muscle relaxants and is only recommended in extreme cases for people that don't respond to other therapies due to its rather nasty side effect of memory loss. What some people know about ECT comes from Nurse Ratched's abuse of her patients in "One Flew Over the Cuckoo's Nest". Setting aside the complex question of ECT's benefits versus its hazards, many people are terrified of the treatment, and by extension those who have received it, because of this film. This film is extremely realistic, and while the author may have been telling a very legitimate story about the abuse of power through medicine, the impact that this story has had on those suffering from mental illness has not necessarily been positive. This particular story has become "the" narrative of psychiatric wards for many people.

My grandmother received ECT treatment in the 1960s. All I know about this part of my family history was that despite being an intelligent and productive individual in her youth and middle age, she fell ill in her later years and my father and grandfather argued at length about the decision to give her this treatment. I don't recall meeting her, she died when I was very young. I just had this basic information from my siblings that the treatment didn't go that well, and then I saw the Jack Nicholson film at some point, and this is what I knew about mental health treatment growing up. This wasn't a nice picture.

The other issue with the dramatic presentation of mental health cures is that they create the notion that psychiatry, and mental health treatment are complex and unreliable voodoo like procedures. My father certainly thought this way about psychiatry. He expressed a great deal of suspicion about doctors, and especially psychiatrists while I was growing up. In Abraham Low's interviews with patients he often comments on how patients distrust his recommendations and expect to be probed with complex methods. In the chapter "Simplicity Versus Complexity In Combating Fears", Low, as the examiner (E) recommends that the patient (P) command their muscles to do what they fear to do.

P: Frankly, that sounds a bit too easy. It doesn't just seem possible that I should cure my fears by moving my muscles. It should take more than that.

E: It will be difficult for you to convince me that it is "a bit too easy" for persons to command their muscles to move if  they feel paralyzed by the fear of making another step. You did not mean to say that my suggestion sounds too easy; you thought it sounds too simple. I shall not enter into a detailed discussion of this very important distinction. I shall merely tell you that I do not want my patients to believe that cures and remedies must necessarily be complex, involved and timeconsuming. It is easy to sit in a chair and to be given lengthy and interesting explanations about how fears arise and develop. That is complex but easy. But if a boy is afraid of swimming or diving it is not at all easy to make him move his muscles for the purpose of a resolute jump. That jump is simple but difficult. Do you realize that you expect to be cured of your fears by means of complex but easy and sometimes glib explanations instead of by means of simple but exacting directions? You want to be studied and analyzed and discussed but you do not want to be told what to do and how to act. What will the most lucid explanations profit you if you are seized with a deep anxiety or a paralyzing panic? In a condition of this kind you are utterly unable to make use of the ingenious and fascinating explanations you may have been given. If in a panic you try to remember what you learned and to reason out what is the sensible thing to do your mind will fail you disastrously. The panic weakens your memory and blots out your reasoning power. All you will be able to do in a commotion of this sort is to apply simple rules. Their very simplicity renders them capable of being employed in a situation in which complex thought is impossible.

P: I do not mean to be contrary, doctor. But it seems to me that when I get into a panic I will not be able to carry out even simple rules.

E: That may be correct for the first and second trial. But if you continue to practice you become ever more proficient in the application of these simple rules.

...

Recovey methods are not complex, they do not require a deep understanding of one's history, motivations, or the basic causes of an illness. Recovery methods are exercise for the mind, and have a similar effect that exercise on the body can have, in that they provide general strength and an overall sense of well being if practiced regularly. It can be difficult to get into a routine of physical exercise. Despite the simplicity of going for a walk every day, many people will not find the time to develop this basic habit, preferring to drive or stay indoors. Practicing Recovery methods is as simple as taking a daily walk, although reaping its benefits can be as difficult because it requires work and consistent effort.

Movies and television often present mental illness as terrifying. The underlying themes show mental health professionals as cruel, incompetent, or abusive individuals who are applying cures that are hideously complex, ineffective or dangerous. While there are real life examples of this conduct, and the mental health industry has numerous issues, most practitioners are genuinely concerned about the people that they are attempting to help. While the mythology around mental illness is fascinating and fun from a theatrical perspective, if one finds oneself suffering from mental illness the many untrue and confusing ideas gleaned from modern media don't provide much helpful or accurate information. At Recovery meetings we emphasize the use of simple tools, these tools can help anyone regardless of the degree of their illness.

Cognitive Behavioural Therapy techniques, like Abraham Low's very simple recommendation to do the things that you fear and hate to do so long as there is no danger, are safe, effective, and not complex. These methods do require sustained effort, and this is one of the reasons that we hold Recovery meetings every week. We provide support for those who want to learn better habits. We are always happy to meet new members, and we encourage you to come to a meeting.


More Information

Suicidal Ideation, Helplessness and Hopelessness

Effectiveness of Peer Support for Depression

About Recovery Hamilton