This is the fourth in a series of articles on emotional intelligence for personal growth.

Self-knowledge is something we all strive towards. But how many of us have done a complete review of our emotions and how they influence our thoughts and behavior? Most people find that pretty hard to do, especially since they struggle to put their feelings into words. We talk about "will power" as the ultimate motivation. It might surprise you to find out that motivation is really emotion.

Emotion in it's simplest form is motivation, "...each emotion offers a distinctive readiness to act; each points us in a direction that has worked well to handle the recurrent challenges of human life." (Goleman, 1995, p4) Entering a state of mindfulness or flow a person reaches "perhaps the ultimate in harnessing the emotions in the service of performance and learning. In flow, the emotions are not just contained and channeled, but positive; energized; and aligned with the task at hand." (Goleman, 1995, p90)

The skill of reading another's feelings is built on self-awareness and flow. People who have good empathy skills are better adjusted emotionally, more popular, more outgoing, and more sensitive. Childhood neglect dulls empathy. Abuse makes people hypervigilent to emotional cues. Empathy predicts intervention to prevent injury to another, certainly an important action in primitive communities.

Expressions of emotions have been found to be a cross-cultural repertoire of non-verbal emotion communication and serve essential functions in cooperative society. "...emotional communication functions to bond social groups. ...language evolved as a more efficient form of grooming and facilitates group cohesion. ...the use of clear signals to communicate intentions and motivations aids the regulation of group processes." (Waller et al 2008)

Human attributes, as important motivation, self-awareness, empathy, non-verbal communication, get little attention in education in our society. The very complexity of our current circumstances makes it our mutual interest to ensure that our community has learned as much as possible about how to understand emotions.

Psychologists have been studying cognitive bias for many years. The various biases demonstrated in these psychological experiments suggest that people will frequently fail to make rational judgments in systematic, directional ways that are predictable. How many of us understand how bias works in our lives?

Many people persistently avoid and suppress negative emotions because of how painful they are. The trouble is, the more they avoid negative emotion, the more negative experiences they have. Those who have experienced emotional excess at it's worst have been traumatized as a result. Revisiting memories of the events seems to stir up the pain all over again for no good reason.

But there is a heavy cost for avoiding emotion. The very act of making a decision and acting on it with any level of motivation depends on emotion. The kind of snap judgments we make in social situations require a finely tuned awareness of our emotional reactions. Even in decisions that allow more time for reasoning, seldom do we have sufficient factual information to make it completely rational. Instead, we have to weigh the information we have with emotional memories of similar situations and intuitions about the current situation to make our best judgment.

People who have learned to numb their emotions have impaired judgment. Their social judgments, their problem-solving and decision making are plagued by systematic error. Many report finding themselves in repeating past mistakes. Many lament that they repeatedly find themselves unsatisfactory relationships, sometimes with abusive and/or chemically dependent partners. They may not recall an error in judgment such as an event they over-looked that might have warned them of the ultimate outcome.

Understanding our emotions is critical to self-knowledge.This is often the part of ourselves we know the least about. However, our ability to read and make use of emotions has been honed over thousands of generations. Even our chimpanzee friends have a similar ability, though no where near as well developed as ours. This conceptual skill is called the "theory of mind." The term theory of mind was introduced into the scientific literature by primatologists who observed a chimpanzee's ability to understand the intentions of an actor in film clips, which enabled her to predict the actor's next move. Theory of mind is the ability to be aware of others' mental states as different from our own. We then use that knowledge to identify others' intentions, motives, beliefs, desires, and feelings in order to interpret their behavior. This is a skill we all have and use all the time. It is critical to communication, building and maintaining relationships, and for most us, our ability to make a living.

A mother, attuned to her child, responded emotionally, physically, and supportively to the child's expressed distress. The mother's theory of her child's mind allows her to anticipate the child's needs and provide for them. Her facilitative movements and empathetic facial expressions communicate her emotional and physical attunement to her child in a way that helps the child convert a felt, physical, sensory experience into a contained mental, conscious awareness of his internal experience, the warm supportive presense of his mother. That awareness enables the child to regulate his affect and distress. It enables the child to develop a sense of self different and separate from his concept of his mother. Mother, then ultimately others, come to be seen as a source of relief, comfort and pleasure. Self-expression comes to be seen as good, loved, accepted, and competent. From this basic begining, the child develops a rudimentary sense of self (Wallin, 2007).

Consciously practiced mindful self-awareness provides an opportunity for the development of a theory of mind for ourselves. Our ability to interpret others behavior utilizes a finely tuned ability to perceive not only a person's behavior, but their unspoken intent. Understanding our own behavior is not so easy. In a real sense, others can see us and interpret our intentions much better than we can. We would rather believe that we know our own minds, that we have a clear idea why we do what we do. Research says that that is often not true. There are all sorts of influences to decision of which we are unaware. Our ability to predict expected punishment is enhanced by our bodily arousal (Dolan, 2002). It would appear that a cool and reasoned state of mind is not as good at predicting punishment. Yet we make some judgments and prepare ourselves for response without any awareness (Kahneman, 2003). Well-learned goals can be activated by environmental stimuli and attendant behavioral plans can run their course without conscious awareness. People can be unknowingly enticed to either trounce an incompetent competitor or protect his self-esteem by words that that encourage acheivement or friendship (Westen, 1998).

Interpreting another's behavior is enhanced by our ability to face and observe that person. We cannot observe ourselves directly. Instead, we rely on our ability to remember our thoughts, feelings and behaviors and make inferences after the fact. There are many unconscious barriers to the accuracy of our memory of our behavior and it's context. We are naturally biased to see ourselves in the right and be suspicious of others. We must learn to correct for our natural biases in order to create a useful theory of our own mind.

There are several skills we can learn and enhance to better understand ourselves and others. Many of these skills are learned in our most cherished relationships, starting with our mothers. We need to be aware of the nature of mental states, that understanding ourselves and others is often difficult and incomplete; people can change their mental state to minimize pain, or disquise themselves. Our interpretations of others are influenced by our own internal states. Feelings often do not follow logic or reason. Mental states evolve from day to day and experience to experience. Parents are highly influential teachers of their children. Their teachings are influenced by that which they learned from their parents. What we learn as children often must be revised based on our adult experiences. Our very presence in a relationship influences the others mental states and in turn our own, often beyond our awareness (Wallin, 2007).

Self-knowledge is often difficult and painful to acquire. Our learning is most robust from a major mistake that we can acknowledge and examine unflinchingly. Healthy self-esteem enhances the accuracy of our self-examination, poor self-esteem distorts it as either positively or negatively based on our willingness to accept the truth. Prediction of our behavior and others is improved with mindful practice and experience over significant time periods.

To be continued....

References

Choi-Kain LW, & Gunderson JG (2008). Mentalization: ontogeny, assessment, and application in the treatment of borderline personality disorder. The American journal of psychiatry, 165 (9), 1127-35 PMID: 18676591
Dolan, R. (2002). Emotion, Cognition, and Behavior Science, 298 (5596), 1191-1194 DOI: 10.1126/science.1076358
Goleman, D. (1995). Emotional Intelligence. Goleman 1995. New York: Bantam Books.
Kahneman, D. (2003). A perspective on judgment and choice: Mapping bounded rationality. American Psychologist, 58 (9), 697-720 DOI: 10.1037/0003-066X.58.9.697
Waller, B., Cray, J., & Burrows, A. (2008). Selection for universal facial emotion. Emotion, 8 (3), 435-439 DOI: 10.1037/1528-3542.8.3.435
Wallin, D. J. (2007). Attachment in Psychotherapy. New York: The Guildford Press.
Westen, D. (1998). The scientific legacy of Sigmund Freud: Toward a psychodynamically informed psychological science. Psychological Bulletin, 124 (3), 333-371 DOI: 10.1037//0033-2909.124.3.333

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I caught this article at Psychcentral.com, Positive Thoughts Make Things Worse for Poor Self-Esteem . It struck me as a counter-intuitive finding for a research study. I've been helping clients build self-esteem for over 30 years and while positive thoughts is not a short road to better self-esteem, it certainly does work over the long run. I'd estimate that at least six months is required to make significant progress with self-esteem from solely refocusing on the positive, and some people require much more time. Several things jumped at me as I read the article. First of all, Dr. Grohol quoted an article from the The Economist of all places. Both articles stated the research was published in this month's Psychology Research and authored by Wood et al (2009). A review of the past three months of that journal produced no article.

So I went to the old reliable, I googled the lead author, Joanne Wood. I came up with several mentions of her at academic institutions and emailed the author for a reprint. I also found another review of the same article by Ed Yong writer for the Science Blog Not Exactly Rocket Science dated May 15th.

The next day, the article arrived in my email with a short note from the author saying it hadn't been published yet! Apparently, there have been some pre-publication prints floating about likely for publicity purposes. This is one of my pet peeves. Articles submitted to peer reviewed journals are intended to inform the academic community and allow scholarly review and comment. The object of repeated review is to ensure the research is sound and is appropriately interpreted. When it appears first in lay publications, the writers who are not scientists often inadvertently distort the interpretation of the research, as I've noted before. That really didn't happen this time. Both the Psychcentral.com and The Economist got the research mostly right. But Ed Yong did a much better job of explaining the fine points.

This time, it's the researchers that make a subtle but major error in an assumption involving an interpretation of a key measurement. Its subtle because it's endemic in our culture. It seems like everyone assumes that negative feelings are harmful. In this case, Wood et al (2009) found that their subjects who had low self-esteem, immediately reported a lower mood and self-esteem after telling themselves sixteen times they are a "lovable person." Interestingly, persons with high self-esteem report only slight, non-significant improvement in self-esteem.

I decided to do an anecdotal demonstration of the "intervention" for my own understanding. After saying to my self 16 times "I am a loveable person", I felt annoyed, a little silly, embarrassed, and was reminded of quite a few traits which make me not always so lovable. But I can't imagine how this would have any long term effect on my self-esteem either way.

An even bigger problem is one that I talked about before and called it Dust Bowl Empiricism. Researchers are so enamored with their professional activities, they demonstrate their preference for inductive research. Wood et al. reviewed all the relevant research on their topic quite satisfactorily, but then failed to do a sufficient review of related theory. In previous post, I quoted Michael Schermer, a columnist with Scientific American, who eloquently asserted that the really valuable research, the kind of research that can fairly readily be used to educate the public, "higher-order works of science that synthesize and coalesce primary sources into a unifying whole toward the purpose of testing a general theory or answering a grand question." To be fair, few researchers venture into grand theory, perhaps because of the dearth of recent reviews, and perhaps because of the few notable exceptions have been eviscerated by their colleagues for their efforts. Sigmund Freud comes to mind. I have sometimes wondered if psychology's love-hate relationship with Freud resulted in an over-emphasis on induction and de-emphasis of deduction and construct validity.

Wood et al. appears to be testing a specific intervention using Cognitive Behavior Therapy (CBT). CBT purports to change feelings by changing thoughts.

While I prefer more psychodynamic conceptualizations, lets approach this issue of negative feelings from cognitive-behavioral point of view for purposes of demonstrating how relevent theory would aide in the interpretation of research. There is conceivable explanation of low self-esteem and associated negative emotion in the concept of "conditioned emotional response" or CER. A person may learn they are not valuable or important by, for example, an invalidating experience. That invalidating experience is remembered in at least two ways, by the facts of the event and by the associated emotions. According to current understanding of neurophysiology, memories of facts and emotions are kept in different part of the brain, presumably by different methods of storage with different processes of recall. The hippocampus and medial temporal lobe are involved in verbalized memories. Emotional memories involve the amygdala.

Sufficient invalidating experiences may lead to low self-esteem. Whenever a sufferer of low self-esteem remembers an invalidating experience or experiences a new one, she is likely to remember the event and feel the emotion associated with the experience.

In the Wood et al. experiment, the lowered mood and self-esteem are experienced after a validating experience. The subject feels the emotions associated with the original invalidating experience of invalidation perhaps because the positive self-talk controdicts the perception of the subject. Wood et al. makes that point. However, what she misses is that the subject is under going extinction of the conditioned emotional response. The subject is experiencing the emotion without the triggering invalidating experience. According to the theory of Classical Conditioning, repeated exposures to the emotion without the associated invalidation will eventually weaken the conditioning. Perhaps this process is complicated by the fact that the alternative experience, validation, is a close opposite to the conditioning stimulus, triggering a strong emotional response.

In my experience, this triggering of a strong negative emotional response associated with past destructive learning without the presence of the negative stimulus actually quickens the de-conditioning. What this experience amounts to is an abreaction, an emotional re-experiencing of the past event in a supportive and nurturing environment.

One point of the research is well taken. A person with an abysmal self-esteem reading a self-help book will find herself ruminating about how wrong it is that she could be so lovable. Such a person, supported only by herself, is not receiving the necessary nurturing due to her low self-esteem. She is likely re-conditioning the CER with more invalidating self-talk.

The reviews of this article did a fair job of presenting the study. However, there is risk in presenting research to a lay audience. The well written review by Yong had unintended consequences. The comments below the article contained some anquished and angry responses:

As a person with very low self-esteem who has been encouraged to think positively and love myself throughout my life, I can only thank Joanne Wood for publishing this study. Packaged one-size-fits-all programs promoting the personal pep talk only serve to make those people already in touch with their mediocre side more acutely aware of their non-value within society.

...and...

And when I feel unloved by one person even i feel like no one at all loves me or values me. How can I value myself when i feel like that. and after going thru a marriage where my ex always devalued me and everything i did if he did not approve of it. being abusive, verbally, mentally, emotionally, and physically... and even tho i have come a long way past this experience, it haunts me and i feel lower then dirt. no positive self talk makes me feel better, only makes me feel worse, cuz i figure if i don't actually believe what i am saying or thinking how can it possibly be true?

Unfortunately, some people with very low self-esteem have been reinforced in their belief that positive thinking can't help. Self-help is best read by the worried well. People with long standing issues with low self-esteem need psychotherapy. Both the authors, Wood et al., and reviewer, Yong, stated this clearly, the other two articles did not. Even so, this knowledge proved harmful to a few. I certainly do not fault the authors for this problem. Yong especially did a great job. One can't ensure everyone reads the entire article or even correctly understands it.

I believe we as professionals who write about mental health have a duty to be as clear and thorough as possible in an attempt to avoid confusion and inadvertant harm. But knowledge is powerful. Sometimes, knowledge mishandled can lead to worsening of symptoms that hopefully brings those in need to help.

Reference: Wood, J., Perunovic, W. Elaine, & Lee, J. (2009). Positive Self-Statements: Power for Some, Peril for Others Psychological Science DOI: 10.1111/j.1467-9280.2009.02370.x

Update 7/15/09: Joanne V. Wood, PhD responds to all the media hype about her research.

Since I heard of all the excitement in the therapy literature about forgiveness therapy, I've been a skeptic. I've worked with a lot of people who have experienced unforgivable abuse. Often they are tortured by their feelings of anger, resentment, helplessness, violation, and shame for allowing themselves to be a victim. They also feel guilt about their anger with the perpetrator so much so they feel morally obligated to forgive the perpetrator. When they do, they seem to feel no personal relief from forgiveness except for less anger and guilt and a better relationship with the perpetrator. But they seem no closer to recovery than before.

I work with persons with depression and anxiety, as well as long standing serious problems with relationships (personality disorder) due to growing up in a chaotic environment. So it is conceivable that forgiveness therapy may have been designed for a healthier population. Seeking to try to better understand this dilemma, I attended a great conference recently taught by Mary Hayes Grieco and colleagues on forgiveness therapy. From the conference flyer:

This day-long course is intended to introduce the counseling professional to a model of wholistic psychological health and an effective method for accomplishing forgiveness that is one of the most useful tools for therapy available today.

You will:

• review current research linking forgiveness with stress reduction


• learn the Psychosynthesis Model of psychological health and wholeness


• learn The Eight Steps of forgiving another and the steps of self forgiveness


• understand how forgiveness brings healing into a family system


• learn how forgiveness brings integration and closure to trauma survivors


• develop strategies for applying the eight steps of forgiveness in a clinical practice

The course material reflects the connection between spirituality and emotional healing but the content is inclusive and non-denominational. We will discuss how to incorporate these concepts appropriately in a secular setting.

It was a small class of 17. Mary and her three assistants seemed to thrive in a small group setting. The atmosphere was most comfortable for listening and it allowed Mary to shine with her skill of personal connection. I got a sense of her therapeutic leadership skills, her gentle and humorous style, and her amazing ability to instill hope with her gentle encouragement. Her eyes positively sparkle with warmth, confidence and belief in her method. She succeeds as well as anyone I've seen providing a secular foundation for spirituality even though her foundations are clearly religious.

She defines forgiveness functionally, rather than semantically. To forgive is to release an expectation that is causing one to suffer, to cancel a debt of demands and expectations that one is holding on to, and to dissolve an attachment that blocks one's flow of love and energy. This is not the moralistic obligatory forgiveness that seems to have locked many of my clients in place.

The core of her method follows:

The Eight Steps of Forgiveness of Another

1. State your will to make a change in attitude
2. Express your emotions about what happened
3. Cancel the expectation(s) you are holding in your mind
   • Shift expectation to positive preference
   • Acknowledge reality
   • Re-state your will to move on; open up to getting your needs met in a different way
   • Release the expectation with words and inner letting go
4. Open up to the Universe to receive exactly what you need
5. Sort out the boundaries: give them responsibility for their actions and take yours; visualize your personal space like a sphere of light around you
6. Send unconditional love to the person
7. See the good in them or in the situation
8. See the good

Notice the physical change and take time to gently integrate it.

Other authors have a bit more elaborate definition of forgiveness. Enright and Fitzgibbons (2000, p. 29), in their book Helping Clients Forgive, defines forgiveness as, after validating the person had been unfairly treated, a person chooses to forgive by willfully abandoning resentment (to which they have a right) and endeavor to respond to the wrongdoer based on the moral principal of beneficence (providing aid without thought of reciprocity or restitution), which may include compassion, unconditional worth (because he is human), generosity (in receiving more than what he deserves), and moral love (concern and respect to which the wrongdoer, by nature of the hurtful act or acts, has no right).

They also define what forgiveness is not: pardon, legal mercy, leniency, condoning, excusing, reconciliation, conciliation, justification, forgetting, restitution, forgiveness for self only. It is not the same as incomplete synonyms of letting time heal, abandoning resentment, possessing positive feelings, saying "i forgive you", making a decision to forgive. They also note confusing similar concepts. Forgiveness is not a quick fix for most. Acceptance and moving on doesn't involve how one feels about the offender. Nor is it in any way cloaked revenge.

Clearly, the forgiveness I had in mind is not what is described here. I had in mind the moralistic obligation to "turn the other cheek", something I've never understood. Mary confidently asserts in her brochure:

Recent research on the relationship of forgiveness to health and happiness demonstrates empirically what religions and philosophers have suggested throughout history: that forgiveness is necessary in order to find peace from life's hurts, losses and disappointments. The ability to move on is critical to completing the emotional healing process.

I think at this point I agree with everything but the use of the word "necessary". The literature review in the presentation gives a compelling argument for the value of forgiveness. But I don't believe I've seen a proof that it is necessary. What the method does contain seems to be a bit broader concept of change. Franz Alexander et al. (1946) defined "the corrective emotional experience:

In all forms of etiological psychotherapy, the basic therapeutic principle is the same: to re-expose the patient, under more favorable circumstances, to emotional situations which he could not handle in the past. The patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences. It is of secondary importance whether this corrective experience takes place during treatment in the transference relationship, or parallel with the treatment in the daily life of the patient.

In my clinical experience, there are two major obstacles to the effectiveness of forgiveness. Reed and Enright (2006) describes them well:

Women who have experienced spousal emotional abuse present at least two unique challenges for recovery. First, learned helplessness (Sackett & Saunders, 1999) develops as a pattern of self-blame in response to the criticism and ridicule by the abusive spouse and often remains well beyond the end of the abusive relationship (Dutton & Painter, 1993). "If only I had done this to please him" quickly deteriorates in the ongoing, unpredictable stress of the abusive relationship to "I am trying to prevent this, but nothing is working" and remains in a residual "Maybe I am worthless and none of my decisions are valid." Therefore, any treatment for these women should demonstrate outcomes in practical decision making and moral decision making....

Second, Seagull and Seagull (1991) described an obstacle to recovery for emotionally abused women labeled accusatory suffering, which entails maintaining resentment and victim status. The assumption in accusatory suffering is that healing the wounds of the abuse will somehow let the perpetrator off the hook. At a deeper level, accusatory suffering may be seen as a defense against the fear that the woman is somehow responsible for her own victimization, a fear that is often inculcated by the victimizer (Sackett & Saunders, 1999). Seagull and Seagull (1991) argued that although accusatory suffering (resentment and victim status) may function as a temporary strategy to help the woman adapt to the extreme experience of spousal emotional abuse, it seriously hinders substantial post-relationship, post-crisis recovery. Therefore, any treatment for these women should demonstrate a change in victim status.

Each of these two obstacles represent major challenges to clients from highly traumatic and abusive environments. The risk of attempting forgiveness prematurely potentially could lock in place both a sense of helplessness and personal responsibility. In that case, forgiveness removes the resentment and improves the broken relationship, it leaves in place the client's vulnerability to recurrence. Reed and Enright (2006) continues:

The FT client is encouraged to tell her own unique story of the abuse experience, with the purpose of working through this story to a healthy resolution that includes forgiveness. During the forgiveness process, the client does the hard work of uncovering anger and shame, grieving the undeserved pain from the abuse, and reframing the former partner (personal history, fallibility, and culpability, yet inherent human worth), with the purpose of relinquishing debilitating resentment.

Key here is the clients' ability to uncover and own their anger and, in particular, the underlying shame. The anger and resentment serves to both motivate the client to face her fears and change their circumstances, while protecting her sense of self from her underlying feeling of responsibility for having allowed the abuse and her own aggressive impulses to avenge their mistreatment. If the resentment is released prematurely, before the shame has been recognized and resolved, the client may be left will little emotional energy to move beyond self-loathing. From Greenberg and Pascual-Leone (2006):

maladaptive shame can be transformed into self-acceptance by accessing anger at violation, self-soothing, compassion, and pride. Thus, the action tendency to shrink into the ground in shame or to flee in fear is transformed by the tendency to thrust forward as part of newly accessed anger at violation or pride at accomplishment. This sequentially ordered pattern is what actually creates confidence.

Thus the negative emotion actually combines with natural positive emotions to trigger a transformation.

Consider this clinical description of a woman with possible borderline personality from Bridges (2006) who failed to respond with an emotional transformation.

Her general tone is one of blame, complaint, and resentment toward her husband for being away and enjoying himself while she is left to deal with the dog's illness. Yet, at no point does she mention that she is angry or even irritated. Her inability to put her anger into words and its relationship to her later waking with a "pain in the neck" almost cries out for interpretation. When she does mention her feelings, it is in regard to the puzzling, perhaps existential statement of feeling "nervous about living a lie." When the therapist makes an explicit attempt to inquire about her feelings related to the recent incident when she had started crying, she responds not by referring to her emotions but by instead focusing on legal details. The overall impression is one of the patient's skipping over the surface of her emotional life via her pressured, externally focused speech as a stone skips over the surface of water.

To summarize, this patient with a "venting" style displayed a pattern characterized by (1) high initial heart rate (HR) with little variability that gradually decreased from beginning to end of session; (2) rapid, incessant speech involving low-intensity expression of negative emotions, primarily complaint, resentment, and externalized blame of others; (3) very low levels of emotional processing (e.g., EXP < 2) characterized by an external focus on frustrating others and events with few references to their personal relevance or meaning or her immediate in-session experience; and (4) self-reports of experiencing intense negative emotions during sessions that were incongruent with her observable emotional behavior. One of the most surprising and interesting findings was that, on a purely physiological level, venting works! This patient showed an average decrease in heart rate from the beginning to end of each session of at least 18 beats per minute (bpm) for 9 of 12 sessions. If one were using progressive relaxation or desensitization and focusing only on decreased arousal as a measure, treatment would appear to be going very well indeed. Although this is obviously not the case, at least for this patient the opportunity to go to a session each week and "get out feelings" while experiencing a very real sense of physiological relief appeared to be very reinforcing in the short term but resulted in little if any long-term change.

So it's not as simple as venting one's anger about mistreatment, but venting reinforces the self-righteous anger by providing temporary emotional relief. To make a long lasting change, it is necessary to ferret out all underlying feelings as well. Resentment often defensively covers shame. The positive aspects of anger can be a strong motivator to transform shame into behavior change. Until this emotional transformation is complete, forgiveness is premature. It's most important to note, that adaptive negative emotions are at the core of movement in transformational therapy. Here anger serves as the energy to transform the shame into pride and confidence. The "debilitating resentment" Reed and Enright (2006) speaks of is not the core of being stuck. It's the shame of an often irrational sense of personal responsibility for ones own trauma and about aggressive impulses for revenge that is covered by the resentment and prevents recovery. Thus forgiveness of the other is not the primary ingredient, but forgiveness of one's self comes first.

Is forgiveness of the offender necessary? That I think depends more on the value system of the client. I believe an emotional transformation from maladaptive anger and shame to angry determination to make changes through self-encouragement and self-nurturance is the primary driver of recovery from trauma. Many of my clients seem to readily make the transformation from resentment to angry determination. Forgiveness, if it comes at all, comes as a consequence of the primary change, effortlessly, later on, as if part of a unforced natural process. Others feel an obligation to forgive and do so as a part of recovery. Unfortunately, too many go through a forgiveness process before they have made an emotional transformation. I find myself trying to encourage them to back track to their anger, which they thought they got over, so they can finally forgive themselves.

To be sure I'm pleased to have another important tool in the therapeutic tool box. However, given the acutity of the population I work with in a short term intensive program, there is probably little utility for full blown group forgiveness therapy. But at the very least I will be much more comfortable with a clients request that they wish to learn to forgive their victimizer.

References

Alexander, F. et al. (1946). Psychoanalytic Therapy: Principles and Application. New York: Ronald Press. Retrieved April 19, 2009, from http://www.psychomedia.it/pm/modther/probpsiter/alexan-2.htm.

Bridges, M. (2006). Activating the corrective emotional experience Journal of Clinical Psychology, 62 (5), 551-568 DOI: 10.1002/jclp.20248

Enright, Robert D. and Fitzgibbons, Richard P. (2000). Helping Clients Forgive - An Empirical Guide for Resolving Anger and Restoring Hope Washington DC: American Psychological Association IBSN: 1-55798-689-4

Greenberg, L., & Pascual-Leone, A. (2006). Emotion in psychotherapy: A practice-friendly research review Journal of Clinical Psychology, 62 (5), 611-630 DOI: 10.1002/jclp.20252

Reed, G., & Enright, R. (2006). The effects of forgiveness therapy on depression, anxiety, and posttraumatic stress for women after spousal emotional abuse. Journal of Consulting and Clinical Psychology, 74 (5), 920-929 DOI: 10.1037/0022-006X.74.5.920

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Aaron Beck, considered the Father of Cognitive Therapy, is an American psychiatrist and a professor emeritus at the Department of Psychiatry at the University of Pennsylvania. He is President of the Beck Institute for Cognitive Therapy and Research that is directed by his daughter, Judith S. Beck, Ph.D.. He is noted for his research in psychotherapy, psychopathology, suicide, and psychometrics, and the Beck Depression Inventory (BDI), one of the most widely used instruments for measuring depression severity. At age 87, the man is still publishing, building on his pioneering work on the cognitive model of depression. In his latest article published in the American Journal of Psychiatry, he recalls his early work:

Caught up with the contagion of the times, I was prompted to start something on my own. I was particularly intrigued by the paradox of depression. This disorder appeared to violate the time-honored canons of human nature: the self-preservation instinct, the maternal instinct, the sexual instinct, and the pleasure principle. All of these normal human yearnings were dulled or reversed. Even vital biological functions like eating or sleeping were attenuated. The leading causal theory of depression at the time was the notion of inverted hostility. This seemed a reasonable, logical explanation if translated into a need to suffer. The need to punish one's self could account for the loss of pleasure, loss of libido, self-criticism, and suicidal wishes and would be triggered by guilt. I was drawn to conducting clinical research in depression because the field was wide open--and besides, I had a testable hypothesis.

I decided at first to make a foray into the "deepest" level: the dreams of depressed patients. I expected to find signs of more hostility in the dream content of depressed patients than nondepressed patients, but they actually showed less hostility. I did observe, however, that the dreams of depressed patients contained the themes of loss, defeat, rejection, and abandonment, and the dreamer was represented as defective or diseased. At first I assumed the idea that the negative themes in the dream content expressed the need to punish one's self (or "masochism"), but I was soon disabused of this notion. When encouraged to express hostility, my patients became more, not less, depressed. Further, in experiments, they reacted positively to success experiences and positive reinforcement when the "masochism" hypothesis predicted the opposite (summarized in Beck).

Some revealing observations helped to provide the basis for the subsequent cognitive model of depression. I noted that the dream content contained the same themes as the patients' conscious cognitions--their negative self-evaluations, expectancies, and memories--but in an exaggerated, more dramatic form. The depressive cognitions contained errors or distortions in the interpretations (or misinterpretations) of experience. What finally clinched the new model (for me) was our research finding that when the patients reappraised and corrected their misinterpretations, their depression started to lift and--in 10 or 12 sessions--would remit.

We owe a lot to Dr. Beck. His cognitive model of depression still dominates how I and most of my colleagues write treatment plans for persons suffering with depression. Our goal is to inspire and teach our clients to change their negative self-evaluations, correct distorted memories, and create an expectation of success. The only problem is depression is not that simple.

Try as they might, many clients are able to recognize what they need to do, understand how their thoughts about themselves and their world need to change, are able to state those changes, and diligently practice them. But when they really need to be able to master their fate, when ruminative thoughts spiral downward into the depths of depression, their efforts quickly collapse and they succumb.

So is the Cognitive Model of Depression wrong? No, I think it's incomplete. There is the biomedical model of depression involving errant neurotransmitter levels treated by various anti-depressants. That discussion is beyond this article's purpose. I'm more interested in what we as therapists can do differently in the counseling office. Of course we need to be sure a severely depressed client is referred for a medication review. But I want to know how we might better facilitate our clients attempts to master their mood. To this end, I will review my recent reading on the subject of emotion and argue to include emotion in a new Cognitive Theory.

I've previously complained about research that so often is focused on small parts and pieces so small that they mean very little to the average person, or even the practitioner in the field. Worse yet, few authors seem willing to reach beyond the data and advance theoretical knowledge. It is at the level of theory development that research reaches into application and education. There seems to have been few willing to work on a new grand theory of psychology based on the nearly 50 year old previous attempts that integrates the research results since that time. There has been some important new knowledge with broad applicability that may foretell a integration of divergent and contradictory psychological models into a single grand theory.

The so-called "objective" human sciences reduces people to parts and pieces so small that we can't recognize commonality or identify our own experiences within the narrow concepts in the models espoused. Science has somehow become primarily inductive. The deep understanding of theoretical deduction seems to have fallen into disfavor. Could it be because it is so easy to pick apart the substance of theoretical systems? I suspect so. The more reductionistic the model, the less likely it can be criticized.

Jonah Lehrer, editor at large for Seed Magazine and author The Frontal Cortex, a neuroscience blog on Science Blogs, wrote a similar point of view in the Los Angeles Times.

Our sensations have been reduced to a set of specific circuits. The mind has been imaged as it thinks about itself, with every thought traced back to its cortical source. The most ineffable of emotions have been translated into the terms of chemistry, so that the feeling of love is just a little too much dopamine. Fear is an excited amygdala. Even our sense of consciousness is explained away with references to some obscure property of the frontal cortex. It turns out that there is nothing inherently mysterious about those 3 pounds of wrinkled flesh inside the skull. There is no ghost in the machine.

The success of modern neuroscience represents the triumph of a method: reductionism. The premise of reductionism is that the best way to solve a complex problem -- and the brain is the most complicated object in the known universe -- is to study its most basic parts. The mind, in other words, is just a particular trick of matter, reducible to the callous laws of physics.

But the reductionist method, although undeniably successful, has very real limitations. Not everything benefits from being broken down into tiny pieces.

[..]If neuroscience is going to solve its grandest questions, such as the mystery of consciousness, it needs to adopt new methods that are able to construct complex representations of the mind that aren't built from the bottom up. Sometimes, the whole is best understood in terms of the whole.

He qualifies his comments in his blog The Frontal Cortex.

I think reductionism can be startlingly beautiful and will always be our primary method of understanding everything. But I think it's important to note that reductionism is not our only method. There are some questions, and these questions happen to include the grandest questions of neuroscience, that can't be answered in such strict and narrow terms.

Gregg R. Henriques talks about the conflict between science and the humanities and offers a unique solution to the problem. He proposes the reason we have difficulty examining the "grandest questions" is to the gap between science and the humanities, so far inadequately filled by psychology. He proposes a gap filling philosophy called the Tree of Knowledge

Click to enlarge.

...psychology connects to each of the "three great branches of learning." More than any other discipline, it is an admixture of natural science, social science, and humanism. Thus a coherent vision for psychology will provide the conceptual infrastructure for a coherent linkage between the natural and social sciences and the humanities. The Enlightenment dream can be realized through the synthesis of psychology.

[..]The unification of psychology was developed through the construction of a new philosophy called the Tree of Knowledge (ToK) System. The ToK System articulates a new vision regarding the nature of objective knowledge. Specifically, it depicts knowledge as consisting of four levels or dimensions of complexity (Matter, Life, Mind, and Culture) that correspond to the behavior of four classes of objects (material objects, organisms, animals, and humans), and four classes of science (physical, biological, psychological, and social). Each dimension of complexity is connected to the dimension beneath it via a theoretical "joint point." A joint point provides the causal explanatory framework how the dimension of complexity evolved. For example, the modern synthesis (which is Darwin's theory of natural selection operating on genetic combinations through time) offers the conceptual framework for the evolution of life. A major and novel feature of the ToK System is the proposition that there are four such fundamental joint points and, correspondingly, four dimensions of complexity. Ultimately, the ToK System is a proposal for the theoretical unification of scientific knowledge.

The ToK System is not just about building bridges within psychology, but is about constructing effective interrelations between psychology and the other sciences and, at its largest scale, between the institution of science and other societal institutions, such as law, health care, governance, the arts, and religion.

In a fascinating text, The Quest for a Unified Theory of Information, Haefner (1999) makes the point that most comprehensive theories of information now recognize the need for a formulation that includes both an information processor and the data being processed. Said differently, information can only be understood as the interaction or product of the data and the processor. This formulation resonates with my views regarding the nature of knowledge. Specifically, it suggests that Knowledge must be thought of as the product of the Knower (processor) and the Known (data being processed). This basic formulation lends itself usefully to the construction of a scientific humanistic philosophy. The two components, the scientific and the humanistic, reflect two different valuations of the knower. In attempting to construct general laws that objectively describe complexity and change, the scientist works to de-value the influence of the specific knower in the knower-known interaction. In other words, the task of the basic scientist is to describe "reality" in as knower-independent terms as possible. Scientific methodology can be thought of as the tools by which this knower-independent knowledge is acquired. However, pure knower-independence (i.e., pure objectivity) is an impossible ideal. Indeed, some of the most crucial developments in modern physics raised enigmatic questions about the relationship between observation, measurement, and knowledge.

In accordance with the analysis offered by Wilson (1998), I believe that the quest for objective truth (defined as accurate models of complexity and change) should remain the idealized goal of the institution of science. But, science is not the only way of knowing. And in the ToK System, science is seen as one particular type of justification system, which has particular strengths (accuracy) and limitations (amorality). Other justification systems (e.g., legal, religious, or political) are explicitly prescriptive, moral systems. I am not alone in isolating the language game of science from the language game of morality. Consider that the Humean is-ought distinction is legendary. The split between science and ethics is well summarized in the following quote from Pinker (1997, p. 55): "Like many philosophers, I believe that science and ethics are two self-contained systems played out among the same entities in the same world, just as poker and bridge are different games played with the same fifty-two card deck."

It must also be recognized that de-valuing the knower and striving for knower independent knowledge is obviously, at one level, a value-laden stance. And it is here that we find the need for the humanistic side of the philosophy. In this system, the humanist values the knower and all of her idiosyncratic subjective elements that contribute to the uniqueness of her knower-known interactions. In other words, the humanist embraces knower relativism and all of the possibilities that emerge with such an embrace. In the process of valuing the uniqueness of the knower, humanism defines humans as the most valued of subjective objects and, thus, unlike the "cold" formulations of basic science, the humanist side of the equation functions as a prescriptive value system. Furthermore, the institution of science is seen as emanating out of, but also being constrained by, humanism. At its most general and abstract level, this constraint is found in acknowledging the impossibility of a "view from nowhere." It is more concretely recognized when one considers ethical constraints and Internal Review Boards that (appropriately) prevent scientists from pursuing particular avenues of investigation. Despite this constraint, the humanist values scientific knowledge as essential to promoting humanity, and is not threatened by the ever-increasing power of scientific explanations. In the end, the scientific and humanistic positions are seen as existing in dialectical tension with one another, and there is the recognition that there is value to be had in both valuing and de-valuing the knower.

Henriques proposes the "Behavioral Investment Theory" to bridge the gap between the life sciences and the sciences of the mind.

Key BIT Principles

1)The nervous system evolved as a computational control center that coordinates the behavior of the animal-as-a-whole.
2)Genes that tended to build neuro-behavioral selectors that expended behavioral energy in a manner that positively covaried with inclusive fitness were selected for, genes that failed to do so were selected against. Thus, inherited tendencies toward the behavioral expenditure of energy are a function of ancestral inclusive fitness.
3)In ontogeny, behavioral investments that effectively move the animal toward animal-environment relationships that positively covariedwith ancestral inclusive fitness are selected for (i.e., are reinforced), whereas behavioral investments that fail to do so are extinguished.
4)The current behavioral investments of an animal can be understood as a function of the two vectors of phylogeny and ontogeny (Figure).

Simplistically, the link between genetics and individually learned behavioral tendancies is expressed in evolutionary selection across multiple generations. How we behave is based in part on what our ancestors passed on genetically and in part our learning history.

Henriques then describes the link between "Mind" and "Culture" with what he calls the "Justification Hypothesis (JH)".

The JH is the notion that humans have an elaborate self-awareness system because the evolution of language created the problem of justification. Humans became the only animal that had to explain why it did what it did.

1.Freud's fundamental observation was that the human consciousness system functions as a justification filter for behavioral investments.
2.This justification filter evolved because language creates the "problem of justification."
3.The Justification Hypothesis provides the psychological foundation for a unified theory of culture and links the natural to the social sciences.

What Does the JH Do?
• Provides the framework for understanding evolutionary changes in mind that led to the emergence of human culture
• Links self-awareness at the individual level to cultural belief systems at the group level
• Defines what makes humans unique
• Provides functional conception of self-awareness
• Links the natural and social sciences

In essense, our conscious awareness is required to conceive of the need to justify our behavior to others. We not only have to see our behavior, we have to imagine how it impacts others, what their perspective might be and how we might influence their relationship with us by an explanation. Obviously, we don't have nearly the information to make a totally rational judgment about a justification in most situations. Yet, every relationship is dependent upon our success in building a place for ourselves in our community through our justifications.

Our ability to reach beyond a rational decision is critical. We don't have complete information, but we do have experience, instinct and emotional memories that can and do influence decisions. The time we spend considering our actions allows us to access all aspects of our decision making apparatus, both conscious, unconscious and between (preconscious). All of these various mechanisms weigh in on our decisions. This is because this process was selected by evolution due to how it has enhanced our survival for a million years. We can not and perhaps never will be able to measure all of our decision making apparatus. It's unlikely we will have a complete set of all the internal and external influences anytime soon.

The very nature of the mind and culture is beyond much meaningful measurement. Current research that is widely accepted by rigorous reviewer is not likely to measure much beyond the basic data itself and therefore have little application in the field. Most of all, as we step into the mind or social spheres, our "processor" (brain) is already engaged and a truly objective measurement is impossible. We've already influenced the outcome by our very presence. Theory however, becomes an important bridge for gaps in the data. Formulating hypotheses needs to become much more than an academic exercise. It needs to provide a bridge from the data to the field.

That is not to say research into human social behavior is not helpful. It is by it's very nature not reductionistic, and so is fraught with greater perils in drawing broad conclusions. But the end result of such research is likely to have meaning for a much broader audience. Researchers need to be willing to step beyond the laboratory and create useful models for broad applications.

Henriques, G. (2003). The tree of knowledge system and the theoretical unification of psychology.. Review of General Psychology, 7(2), 150-182. DOI: 10.1037/1089-2680.7.2.150

The Journal of the American Medical Association [February 21, 2007--Vol 297, No. 7] published an important article on grief, Maciejewski et al (2007). While it's hardly definitive research, it represents an exciting trend in research that I've seen in recent years. Researchers seem more willing to take some risks with the rigor of their research models to produce information that is immediately relevant to practice. While, we are a long way from having clear guidance towards an evidenced-based practice in psychotherapy, testing models in active use in the field provides immediately useful information.

Grief is one of the most common issues that emerge in psychotherapy. Grief unfolds in a purposive and meaningful way from the first awareness of loss. The grief process guides us through the painful reassessment and renegotiation of our needs and goals. What that process entails appears to have not been researched empirically before Maciejewski et al (2007) made their ground breaking attempt. They did a great job of researching an abstract and difficult to define topic and made a meaningful attempt at measurement. They also managed to validate, for the most part, a widely held belief about grieving.

A four stage theory of grief was first discussed by Bowlby [Bowlby J. Processes of mourning. Int J Psychoanal.
1961;42:317-339.]: shock-numbness, yearning-searching, disorganization-despair, and reorganization. Kubler-Ross E. in her widely read book, On Death and Dying, adapted Bowlby's model into a 5 stage theory. Jacobs Pathologic Grief: Maladaptation to Loss asserted that a normal grief process is completed within 6 months following the loss of a loved one. He also postulated a five stage theory: numbness-disbelief, separation distress (yearning, anger, anxiety), depression-mourning, and recovery.

Maciejewski et al (2007) took an odd combination of Kubler-Ross's and Jacob's model as the hypothesis to be tested. The study interviewed only persons who experienced a death of a loved one that was from natural causes, not trauma. Here I think they made a good judgment that difference causes of death would complicate the experience of grief. The interview method was described as a "single item interview screening" which was not defined clearly. The researchers took a single item from the Inventory of Complicated Grief-Revised and used a five point rating scale and asked participants to rate their experience of grief on each stages: disbelief, yearning, anger, depression, and acceptance at some point between 1 and 6 months, 6 and 12 months, and 12 and 24 months post loss.

Ideally, all individuals would have been assessed immediately after the loss rather than beginning at month 1 post loss. Due to respect for the initial mourning period and institutional review board concerns about harm to participants, we did not interview individuals within a month of the death. In addition, it would have been better to analyze data that reassessed individuals each month from 0 to 24 months postloss. However, no such data exist nor does the stage theory specify in what month postloss each stage would predominate. And, although we acknowledge that other grief indicators might have been used, the various proxy measures (ege.g.stunned for disbelief, bitterness for anger, hopelessness for depression, quality of life scores for acceptance/recovery) all revealed remarkably similar patterns to those presented herein. We chose to present the items that fit most closely with the stage indicators illustrated in the literature.

The authors reported that they partially confirmed the Kubler-Ross/Jacob model. Click on the image to enlarge.

Reflected in their data, the authors found a surprisingly similar stepwise process of recovery at least partly confirming the stages, even the order by each each stage was addressed. "The odds of each of these indicators peaking in this exact sequence by chance is miniscule."

But they also found some inconsistencies. Acceptance and yearning were endorsed most frequently beginning from the first interview increasing through the 24 month period. Traditional grief stage theory postulates that people experience disbelief immediately following the death of a loved one and eventually arrive at acceptance. Given the researchers interview method of a single item, presumably presenting the measures without explanation by the interviewer, it seems likely there was little reason to think that what the participants were identifying as disbelief and acceptance were not consistent with the model. Elizabeth Kubler-Ross defined denial as a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the situation concerned. Acceptance was described as varying according to the person's situation, although broadly it is an indication that there is some emotional detachment and objectivity. It seems most likely, participants endorsed the scales in a socially acceptable way. "Of course I accept that he died." The disbelief or denial in my experience refers to an awareness of the duality of a cognitive awareness of the fact of death, but an emotional disbelief manifest in more subtle ways such as speaking of the deceased in present tense.

It's curious that the authors put so much into the order of the grief process, even though their two models don't agree on any one order. It even seems counter-intuitive that a human emotional process could be assumed to take on even an appearance of linearity. As in the example above, even the extreme ends of the process, acceptance and disbelief, overlap. The other inconsistency is about one of the clinical recommendations. The authors state that the study supports the theory that a six month duration of the grief process would be expected. Anything beyond six months may warrant a clinical assessment to determine if there was a complicated grief process in need of treatment. Their own data (see the figure above) suggests participants continued their grief process for nearly 18 months.

As a practicing clinician, it's hard to imagine either author intended to describe the stage theory as a linear step by step model. Also neither author suggested an appropriate length of time for grief. It has been often stated in my training that grief takes no particular length of time but is unique for each person and situation.

The final comment I have is about the use of the word "depression" in all the grief models. It appears to me that the general use of the word "depression" has been confused by the concept of clinical depression. A normal feeling has been confused with pathology. I'd like to see the word "sad" used in this context. Sadness is a normal part of grief. Normal grief may have some things in common with depression, but it is harmful to pathologize grief. Our culture has too much trouble with accepting intense negative feelings as "normal" and go to great self-destructive lengths to escape them. Sadness provides us with an intuitive guide to recovery if we listen closely and feel it fully.

Regardless of these comments, it's the kind of research I love to see. Anxiety Insights had a recent post on another great sounding article about grief.

There are two guarantees in every person's life: happiness and sadness. Although lost opportunities and mistaken expectations are often unpleasant to think and talk about, these experiences may impact personality development and overall happiness. A seven-year study conducted by Laura King, a University of Missouri researcher, indicates that individuals who take time to stop and think about their losses are more likely to mature and achieve a potentially more durable sense of happiness.

"People are generally in a hurry to be happy again, but they need to understand that it's okay to feel bad and to feel bad for a while," said King, who teaches psychology in the College of Arts and Science. "It's natural to want to feel happy right after a loss or regrettable experience, but those who can examine 'what might have been' and be mindfully present to their negative feelings, are more likely to mature through that loss and might also obtain a different kind of happiness."

Unfortunately, I can't get a free copy of this article for a year! It sure sounds like the authors made another attempted to unfold the process of grief. As with all emotions, there is a duality of process between the cognitive and emotional. The more we know about the emotional aspect, the more we can make sense of the emotion and apply it meaningfully our lives.

Here is a quote I've used before from a former psychiatrist blogger shrinkette on the process of grief. I think it illustrates well the emotional challenge of grieving and how difficult it is to put it into words.

You go on. You go on. You bring the person you love inside you. That is how you cope. You make him or her live within you. The whole experience I had with my children is in me. It is nowhere else I can see. I can see a photograph, I can feel sad, I can read a poem, but the experience of having them within myself is what matters.

Sometimes there is just nothing more to say.

Maciejewski, P.K., Zhang, B., Susan, B.D., Holly, P.G. (2007). An Empirical Examination of the Stage Theory of Grief The Journal of the American Medical Association, 297(7), 716-723.

Shame has been a particular interest for me. It has appeared repeatedly as a major barrier in therapy, especially in those for whom therapy has failed in the past. It takes a lot of courage to re-enter therapy after feeling it was previously insufficient. Fortunately, a person returning to therapy after a less than satisfactory experience is significant motivated to try new ideas.

Agreeing to therapy is a humbling experience in and of itself. The American culture so values individualism, asking for help is often viewed as a sign of weakness, perhaps more likely by those who need help the most. I have previously written about the pervasiveness of shame in many long term issues I've seen in therapy. It's almost as if the person attempts to punish himself into change. But the misery extends well beyond what is helpful in motivating change into a self-imposed purgatory. Eventually, the person becomes so desperate to escape that they engage in self-destructive compulsive and addictive behaviors to temporarily escape the pain. Unfortunately, once the consequences of the escape behaviors becomes apparent, misery returns worse than before. This pattern of habitual and cyclical self-recrimination and escape could explain life long patterns of substance abuse and chronic maladjustment including depression. I've been finding some fascinating research that explores shame in therapy that has motivated some intensive research.

Hook and Andrews (2005) reviewed the literature on shame in therapy. They found that shame has recently been found associated with onset and course in depression, especially in chronic and recurrent depression. Personality traits that evoked shame were "as likely to be consequences or concomitants of depression as they were to be precursors." They speculated that "feeling ashamed of personal qualities and behaviors may lead to a chronic course of the disorder by affecting disclosure of the issues involved, thereby impeding therapeutic progress".

Hook and Andrews (2005) also studied questionnaire data of self-described persons who suffered from depression to "examine relationships between shame, disclosure in therapy, and current symptoms...." Of the study's 85 respondents, 54% withheld significant information from their therapist, 42% withheld information related to depressive symptoms and behaviors. Nearly 3/4 of respondents who withheld information said they did so because of shame. Most intriguing, those who were no longer in therapy who also had not disclosing depressive symptom/behaviors had significantly higher depressive symptoms currently than other participants. The study combined with the article's review of the literature, found that "significant relationships have been established between shame-proneness and non-disclosure of symptoms/behaviors in both therapy groups, and of this type of non-disclosure and current depression symptoms in those no longer in therapy."

This is the kind of research I can bring back to work tomorrow and use. It also appears to be a research approach and topic I may be able to emulate. One point they make in the discussion is that while many authors have spoken against assessing shame directly, "if one does not ask, one does not find out about such experiences". And the information that might be withheld otherwise would likely involve depressive symptoms and related behaviors. This finding replicates a previous study of women with eating disorders, which found a significant association between non-disclosure in therapy and shame that involved eating disorder symptoms. I have tended to teach my clients to expect that they will find that those things they most wish not to share are likely to be need disclosure and work to assure a good outcome in therapy.

Another interesting twist in the discussion was an attempt at explaining why "disclosure of symptoms may be more important for depression recovery than disclosure of other upsetting issues and experiences. One explanation is suggested by evidence from Pennebaker and Beall’s (1986) study that disclosure of feelings confers more benefit on long-term health than disclosure of purely factual information." Does that sound clinically sound or what? Ever had a client not want to share the details of a particularly shameful event? I've had some good success encouraging them to share the feelings about the event and how it affected them later, while leaving out the details.

This article is both inspiring of my interest in research as well as immediately practical in clinical applications. I'm going to be digging through this bibliography next week.

Hook, A., Andrews, B. (2005). The relationship of non-disclosure in therapy to shame and depression. British Journal of Clinical Psychology, 44(3), 425-438. DOI: 10.1348/014466505X34165

Recently, a post at Anxiety and Depression Treatments Blog got my attention. It refers to a BBC NEWS article titled "Paranoia 'a widespread problem". The article is about a survey done in the UK by the Institute of Psychiatry at King's College London. The blog characterized the results as laughably high. Here is an excerpt from the BBC article.

One in three people in the UK regularly suffers paranoid or suspicious fears, clinical psychologists have found. A team at the Institute of Psychiatry at King's College London interviewed 1,200 people about whether they had thoughts about others doing them harm. They found levels of paranoia were much higher than previously suspected - and almost as high as those for depression and anxiety. The researchers say paranoia can cause real distress.

The study found that:

• Over 40% of people regularly worry that negative comments are being made about them
• 27% think that people deliberately try to irritate them
• 20% worry about being observed or followed
• 10% think that someone has it in for them
• 5% worry that there is a conspiracy to harm them

The article seems to imply up to 50% of those surveyed reported paranoid thinking. Without a context, indeed the bullet points above seem to say just that. I went to the Institute of Psychiatry at King's College London website and found a link to the article.

The study was based on an anonymous Internet survey of students at King’s College London, the University of East Anglia and University College London invited by e-mail to participate in a survey of ‘everyday worries about others’. The web based survey method was considered by the authors "to provide a safe environment for
survey participants to disclose suspicious thoughts. Internet research has been found to reach the same conclusions as laboratory-based studies (Birnbaum, 2001)." However, this method would very likely create conditions where an exaggerated response might be expected.

[The authors concede that] people who self-select for questionnaires of this type may be more prone to psychological disturbance, or the stigma of appearing so might skew the sample in the opposite direction. Thus, our investigation in a selected group indicates a need for more elaborate and more truly epidemiological studies.

One of instruments in use was included in tables with the resulting responses. So I responded to the survey honestly. Given my work, I meet a larger proportion of people with personality disorders who maybe worthy of suspicion than perhaps the average person might contact on a day to day basis. I remember the experience I had as an adolescent and college student where I was exposed to a disproportionate number of rebellious young people. I had every reason to be suspicious of many of my peers, so I suspect my current contacts through my practice might represent an experience in college in the upper third of peer stress. Indeed two-thirds of the respondents were women, perhaps more likely to experience the stress of peer pressure. Interestingly, the responses between men and women in the survey were reported to be not significantly different.

It is apparent in going through the Paranoia Checklist, that I experience a lot of suspicion in my life, but not as much stress about it as one might expect from a college student among peers. The authors had a similar concern.

There are also issues concerning whether the experiences assessed are actually unfounded; questionnaire studies may include an unknown proportion of paranoia that is realistic and therefore well judged and appropriate. It is also unknown whether any of the participants had received treatment for a psychiatric disorder, and what the level of substance use was in the group.

So the authors appropriately review all the possible problems with the survey, Their bullet points are clear and not misleading listing the limitations.

CLINICAL IMPLICATIONS

• Having suspicious thoughts is a common experience and provision of this information may help reduce patient distress.
• Feelings of hopelessness and lack of control may contribute to the occurrence of more suspicious thoughts, whereas gaining distance from such thoughts and evaluating them may reduce such experiences.
• Not talking to others about suspicious thoughts, feeling vulnerable and behaving timidly with others may be factors in the development of paranoia.

LIMITATIONS

• An epistemologically representative sample was not recruited.
• The group mainly comprised young adults have higher rates of suspiciousness.
• Only cross-sectional associations between paranoia, coping strategies and social^ cognitive processes were examined.

The BBC article really does a poor job of conveying the information of the study. The reporter seemed to have latched onto the stigmatizing word paranoia and grabbed at statistics that sensationalized rather than communicated accurately the results of the study. In fact, there was some very interesting results that a worth considering in the context of the limitations of the study.

In the press release announcing the study to the public, the agency does a nice job of summarizing the results. The study I can fault at only one point. The authors began using the word paranoia in the discussion to refer to at least the upper end of the hierarchy of suspicious thoughts.

Approximately 10–20% of the survey respondents held paranoid ideation with strong conviction and significant distress. [...] If paranoia is an everyday phenomenon, which many people manage well, then it provides an opportunity to gain clinically useful information on optimal ways of coping.

Substitute the phrase "suspicious thoughts" for paranoia and the miscommunication goes away. The press grabbed the word "paranoia", guaranteed to grab attention with a catchy headline, as reflecting the primary focus of the research which was in fact focused on suspicious thoughts. With the ready access of research to the general public via the Internet, authors need to be aware of the potential misunderstandings of lay persons reading their articles.

MentalHealthCare.org.uk

The results indicate that suspicious thoughts are a weekly experience for many people. For example, 30-40% of participants had ideas that negative comments were being circulated about them. 10-20% of those who took part in the survey had paranoid thoughts that they firmly believed and which caused them significant distress. This suggests that there is a significant group of people in the population who suffer distress as a result of paranoid thoughts but do not seek treatment from mental health services.

The authors believe that this may be because many people feel uncomfortable talking about suspicious thoughts and fear being thought of as ‘paranoid’, a term which has stigma attached to it.

According to the survey people with frequent and distressing paranoid thoughts tend to deal with them by isolating themselves, giving up activities and feeling powerless or depressed. These so called coping strategies have been shown to be less effective than other strategies in reducing the distress caused by such thoughts.

People with less severe paranoid thoughts, however, tended to cope with their suspicious thoughts by keeping things in proportion (known as ‘not catastrophizing’), and by keeping enough distance from their thoughts to see them in an unemotional way. These techniques have been shown to be more effective than those used by people with more severe paranoid thoughts. It is not clear from this survey whether using a less effective coping method causes more paranoid thoughts or whether the paranoid thoughts make people more likely to use less effective coping methods.

The authors also found evidence that not talking to other people about suspicious and paranoid ideas can lead to a greater number of such thoughts. In addition people with low self-confidence are more likely to suffer suspicious and paranoid thoughts. The researchers believe that low self-confidence can produce feelings of being vulnerable to some form of attack and so lead to feelings of suspicion.

The researchers call for treatments for paranoia to take into account the findings of this survey. Firstly mental health professionals should accept that paranoia is a very common experience. Secondly people dealing with paranoid thoughts should be encouraged to talk about their experiences. Efforts should be made to improve the self-esteem of people with paranoid ideas, and they should be encouraged to feel in control of their situation. All of these techniques are used in Cognitive Behavioural Therapy, a psychological treatment that is increasingly being used to treat psychosis and schizophrenia, conditions that often involve paranoid thoughts.

Perhaps the most significant result of the study was initial suggestions in the data that suspiciousness belongs to a continuum including paranoia.

Our survey clearly indicates that suspicious thoughts are a weekly occurrence for many people: 30–40% of the respondents had ideas that negative comments were being circulated about them and 10–30% had persecutory thoughts, with thoughts of mild threat (e.g. ‘People deliberately try to irritate me’) being more common than severe threat (e.g. ‘Someone has it in for me’). In contrast, only a small proportion (approximately 5%) of respondents endorsed the checklist items that were the most improbable (e.g. that there was a conspiracy).

Nevertheless, the rarer and odder suspicions – characteristic of clinical presentations – occurred in tandem with the more common and plausible experiences. The rarer the thought, then the higher the total score indicated by its presence. There has been no previous examination of paranoia in this way. The findings indicate a hierarchy of paranoia [see diagram]: the most common type of suspiciousness is that of a social anxiety or interpersonal worry theme; ideas of reference build upon these sensitivities; persecutory thoughts are closely associated with the attributions of significance; as the severity of the threatened harm increases, the less common the thought; and suspiciousness involving severe harm and organisations and conspiracy is at the top of the hierarchy.

The implication is that severe paranoia may build upon common emotional concerns, consistent with a recent cognitive model of persecutory delusions (Freeman et al, 2002; Freeman & Garety, 2004). The interesting questions therefore concern the identification of the additional factors that contribute to the development of severe paranoia and whether there are qualitative shifts in experience at the top end of the hierarchy (note that individuals at the higher end of the hierarchy tended to endorse all their suspicious thoughts with high levels of conviction and distress). The survey findings also indicate that there is a continuous (exponential) distribution of total number of suspicious thoughts in the general population, although the thoughts appear in a hierarchical arrangement. No distinct subpopulation was identified. This therefore demonstrates correspondence to common mental health disorders such as depression and anxiety.

It's apparent similarity to depression is not a surprise. It has always struck me that depressive and paranoid thinking are special cases for obsessions based on the thematic content of the thought. This confirmation continues the cry for a medication focused on relieving the the compelling nature of obsessive thinking of all kinds. The driving repetition of the thought may have a major responsibility for danger to self and others. Repetitive themes of shame may well lead to suicide ideation and attempts. Obsessive thinking regarding persecution involving a particular person seems related foretell vengeful think and ultimately homicidal ideation and attempts. More traditional obsessive thinking is thematically focused on safety in the form of checking to confirm no hazard and compulsive cleaning to prevent exposure to germs. It makes less sense to me to separate diagnoses based on thematic content than structure and pattern of symptoms. Not surprisingly, Anafranil and the SSRIs have had notable success with obsessive symptoms and depression. I've only seen a few examples of paranoid thoughts treated by SSRIs, all as I recall were relatively successful. It would seem a more targeted medication related to repetitive thought patterns would be more fruitful in treating the obsessive symptom.

Freeman, D., Garety, P.A., Bebbington, P.E., Smith, B., Rollinson, R., Fowler, D., Kuipers, E., Ray, K., Dunn, G. (2005). Psychological investigation of the structure of paranoia in a non-clinical population. British Journal of Psychiatry, 186(5), 427-435.

Sunday I found a disturbing article in a blog that has a good reputation. Dr. Peter Breggin at The Huffington Post wrote about the FDA decision to require a "black box" warning on the anti-depressant medication Paxil because of the risk of suicide in the beginning of treatment. Dr. Breggin is the author of the book Talking Back to Prozac which is highly critical of the anti-depressant medication Prozac. In his post at Huffington's, Dr. Breggin makes statements that appeared designed to attract attention at the expense of misleading the reader.

I've written about the problem with reading articles about mental health in the press. Essentially, reader beware, what you read many be misinforming you. Sometimes misinformation occurs in the interest of selling a publication. Science has it's own issue with chasing the money.

Research is expensive and finding the means to fund it can be difficult. It's also a necessary process to advance a science. Psychotropic medications are extremely expensive to develop and submit to the FDA for approval. The FDA makes the decision to approve a medication based on research completed by the pharmaceutical companies who have a vested interest in the outcome. It's pretty clear that this procedure invites significant inappropriate salesmanship into the research process, but the alternative is likely even more expensive. The only alternative I can imagine would require a large government bureaucracy to manage a process that may be no less fraught with potential for corruption due to the millions of dollars at stake. I can't criticize a system when I can't imagine a working alternative.

Meanwhile, a comprehensive review of all studies of anti-depressant drugs submitted for approval to the FDA showed that when the studies are taken as a whole, anti-depressants don't work.

To support this statement, he sites only two sources when there are literally thousands of articles out there that have different conclusions. Antonuccio et al (2002) makes some quite critical statements about the FDA approval process and questions the magnitude of efficacy of anti-depressant medications. His second source is his own book, Talking Back to Prozac. Antonuccio et al (2002) is not a research study. It is a commentary about a review of the literature in the same publication: Kirsch et al (2002). That particular volume of Prevention and Treatment is full of supporting and detracting articles about the Kirsch et al (2002) study. It's results are universally described as important, but they range in characterization from exaggerated and politically and financially motivated to underestimated.

Most of the articles in Prevention and Treatment Volume 5 note that anti-depressant medications ARE shown effective in the Kirsch et al (2002) study. Even Kirsch et al (2002) conclude anti-depressants are effective, just not as much as one would like to see. One has to keep in mind that drugs affect individuals differently. While on average across large numbers of persons in the study, the magnitude of the drug effect may be relatively small, a sizable proportion of the individuals could have substantial benefit from medication.

Dr. Breggin next makes a statement that implies taking prescribed anti-depressant medications have a following because it gives users a high like recreational drugs.

Of course, many people feel helped by antidepressants, as well as many other psychiatric and even recreational drugs. The placebo effect is enormous. In addition, the artificial euphoria or emotional flattening produced at times by antidepressants may provide temporary relief at the cost of rationality and effective dealing with life.

The uninformed reader very likely would be discouraged from using anti-depressant medications and misinformed that they make a person "high". Not only does this statement misinform and confuse, it adds to the stigma of mental illness by equating anti-depressants to recreational drugs.

Next Dr. Breggin takes the argument to unsubstantiated scare tactics.

It's time to say again what I've been saying for too many years on end. The antidepressants aren't antidepressants. They are more likely to make a person worse than better. More tragically, these toxic agents push many people over the brink into suicide and violence.

He cites no evidence that anti-depressants are "more likely" to make a person feel worse. Even the article he cites says otherwise.

Meanwhile, the antidepressants are very difficult to stop taking. Withdrawal from antidepressants can lead to "crashing," with agitation, violence and suicide. Withdrawal from these noxious drugs should be done slowly with experienced clinical supervision. These drugs are not only unsafe to start--they are dangerous to stop. The best approach to antidepressants: Don't start taking them.

Now Dr. Breggin implies anti-depressants are effectively an addictive drug with a characteristic withdrawal syndrome. There is no evidence of this cited. I've not seen any literature that supports this assertion. In fact, one of the key requirements of an addictive drug is that a person develops a tolerance for the medication requiring an periodic increased dose. My clinical experience has not born this out. Instead, what I've seen across many patients, a life time course of medications requiring occasional adjustments, both up and down or a change to a different drug, typically attributed by the prescribing psychiatrists to changing body chemistry over time and age. That is not even close to the typical abuse pattern of patients addicted to, for example, benzodiazopines where they gradually increase their dose over a relatively short period of time supplementing the prescribed supply with illegally obtained prescription drugs, street drugs and alcohol.

The increased incidence of suicide attempts during the medication trials is of concern. However, what this might be attributed to is unclear. I know from my clinical experience, many people report uncomfortable side effects, including flu-like symptoms and increased anxiety that have been known to make some patients worry about "going crazy". These side-effects may well be enough to induce a suicide attempt in someone who is already depressed and hopeless with suicide ideation.

As I have stated before, medications are an important part of treating depression. But they should not always be the first attempt to intervene. Research has shown repeatedly that psychotherapy and medication used together has consistently the best outcomes. I suggested on April 1,

that the indications for anti-depressants be limited to (1) those people who show neuro-vegetative signs of depression, especially significant sleep deprivation due to insomnia or sleep disturbances and a significant loss of weight due to loss of appetite, (2) a moderate or high risk of suicide as indicated by a lethal and available plan, and (3) after a course of psychotherapy of say six sessions produced insufficient improvement in functional impairments in relationships, productivity at work, keeping up with chores, etc, that the therapist refers the patient to their physician for a medication evaluation.

It appears that the literature agrees with me. In a companion article by Irving Kirsch and Alan Scoboria (2002), the authors offer much the same advice:

In the meantime, what are the alternatives for treating patients? Imagine having a choice between four treatments. Treatment A produces a large therapeutic response but also a large number of adverse effects, including diarrhea, nausea, anorexia, sweating, forgetfulness, bleeding, seizures, anxiety, mania, sleep disruption, and sexual dysfunction. Treatments B and C produce therapeutic responses that are almost as great as those produced by treatment A, but without the adverse effects. In fact, the side effects produced by Treatment B are beneficial (e.g., better general physical health). However, the therapeutic effects of Treatments B and C have been evaluated in relatively few studies. Treatment D has been assessed in many comparative studies, in which it has been found to be as effective as Treatment A in the short term and more effective in the long term. It does not produce adverse effects. Given a choice between these alternatives, which would you choose?

Of course, these alternatives are not merely hypothetical. Treatment A corresponds to SSRIs, and the list of side effects is drawn from those that have been shown to be produced by these medications. Treatment B is physical exercise, which has been reported to have lasting therapeutic benefits in the treatment of major depression. It may be nothing more than a placebo, but if so, it is one with desirable rather than adverse side effects. Treatment C is bibliotherapy, another low-cost treatment with demonstrated effectiveness and little danger of side effects. Treatment D is psychotherapy. As noted by Antonuccio et al (2002), "psychotherapy (particularly cognitive therapy, behavioral activation, and interpersonal therapy) compares favorably with medications in the short term, even when the depression is severe, and appears superior to medications in long-term comparative studies. Given these data, antidepressant medication might best be considered a last resort, restricted to patients who refuse or fail to respond to other treatments.

Part of the problem here is that treatment of depression in a clinical setting contains many components only one of which is medication. To test the effectiveness of a medication, a treatment group receives the medication and a control group receives a sugar pill. Both the treatment group and the control group receive the sort of care that is an integral part of a clinical setting. The part of the treatment that is not mediation is called "placebo". Rehm (2002) describes this placebo. The author lists life events, social support, hopeful expectations, and biochemical changes that accompany treatment and enhance immune function and biochemical balances that facilitate recovery from depression. Rehm also lists spontaneous remission and regression or random fluctuation in the measured factors of depression attributable to the instruments measuring them. These final two factors are essentially improvement that can't be attributed to anything else.

While I understand the argument that without a placebo control, one can never hope to measure the effect of treatment attributable to medication alone. However, imagine if a patient picked up his medication from a grumpy, shaming pharmacist, do you think the medication would be as effective? I think not. The placebo effect is as integral a part of treatment as the medication. It's effects on treatment are not well known.

The other problem is that the typical medication trial used for justifying the approval to the FDA is 6-8 weeks, mainly to contain the costs of research. Anti-depressant medications just come up to therapeutic levels in the blood in the fourth week. From my clinical experience, those four weeks of waiting for the therapeutic levels are quite uncomfortable for the sufferer. The client is waiting for relief from a miserable condition made even more so by the well known side effects of starting and ending anti-depressant treatment. By the end of the fourth week, the clients sense of equilibrium at best is improved but tenuous. Recovery continues over the next few weeks in a stutter-step fashion: one step forward, two steps back, two steps forward, one back. To measure effectiveness in the 6th to 8th week is not likely to show anything more than the beginings of therapeutic effect.

Finally, as demonstrated convincingly in the recently released mega-study of anti-depressants called STAR*D2:

These results highlight the need for longer treatment duration and more vigorous medication dosing than is current practice in order to achieve optimal remission rates. Informed triage or critical decision points (i.e., the discontinuation of patients who experience minimal benefit after 6-9 weeks of treatment) allow for extended dosing for those who are benefiting, while curtailing extended treatment for those who experience minimal benefit after a substantial treatment period. The measurement-based care methods used in this study were easily implemented in actual practice. Controlled trials of this approach in practice are recommended.

And from my previous post on STAR*D2:

The important finding in the STAR*D Part 2 study was that persistence in seeking a combination or a change in medication increased remission rates. If one counts each medication trial as 6-8 weeks and add to this 12 to 16 weeks or more for psychotherapy to address complicating factors like anxiety, a history of mistreatment, abuse or trauma or substance abuse, it's reasonable to expect at least 16 weeks of concerted, persistent and painful effort to make progress with a resistant depression. Many sufferers are tempted to give up after the first attempt at treatment.

There is no reason to discourage use of anti-depressants. There is however reason to be concerned. I think the concern is sufficient to require frequent monitoring by the prescribing physician and consultation by a psychiatrist whenever there is suicide ideation.

I complained to Huffington Post about this article. I encourage you to join me in encouraging Huffington Post to reconsider the content of this article by emailing them here.

Kirsch, I., Moore, T.J., Scorboria, A., Nicholls, S.S. (2002). The emperor's new drugs: An analysis of antidepressant medication data submitted to the U.S. Food and Drug Administration. Prevention & Treatment, 5 (1)

Here is an article about a modest but potentially significant piece of research. They took existing data and studied any correlation between socio-economic status and mental illness. Not surprisingly to those familiar with the subject, there was a modest but significant association between being socially disadvantaged with a higher incidence of mental illness. The population surveys they used were shown to be inadequate to the task. Specific ideas were suggested on how to better collect such data.

The most important part of this research was the discussion about future research. The study suggests a "nurture" factor to mental illness. While the documentation is not clear, there is justification to pursue better research. While one could argue that the genetic "causes" of mental illness could be higher in generations of poor people, it seems unlikely that multi-generation poverty would amount to the majority of the population surveyed. Nor is genetic tracing of mental illness risk likely to be related to all the factors measured and found to be related.

There can be no doubt now that disadvantaged groups in European populations experience more anxiety and depression, measurable on standard instruments and representing significant suffering for individuals, and serious loss of production and social function, with important consequences for children, communities and work-places. We can begin to define populations at risk, though this will still be rather generalised.

The scientific literature from major population studies currently permits very little detailed comparitive analysis of risk factors other than the three presented above, education, employment, and income / material standard of living, which can be measured in fairly similar ways in all western societies. Social Class or Socio-Economic Group can only be a proxy for these, and, no doubt, other more precise and tangible markers of social position and social experience. We now need focussed investigations into causative factors and possible means of prevention, and evaluations of means of relieving suffering and improving function.

The most exciting part of this discussion is the prospect of breaking down socio-economic factors into what might be considered environmental risk factors for mental illness. My clinical experience says that child abuse and neglect is more directly related to episodes of mental health disability than most seem to believe. Perhaps we can make some progress towards convincing the general population to teach resilience skills and child-rearing in high schools.

Fryers, T., Melzer, D., Jenkins, R., Brugha, T. (2005). . Clinical Practice and Epidemiology in Mental Health, 1(1), 14. DOI: 10.1186/1745-0179-1-14