Sunday, December 16, 2012

Conservatives, Liberals, & Libertarians: How We Reason and How We Relate

Last month, during the second week of November, several of my clients mentioned the election results during their sessions.  Some felt optimistic and jubilant about the results; others were anxious, depressed, disheartened, or frustrated.  Some shared mixed feelings and ambivalent thoughts; still others were indifferent to the entire process.  Because I'm blessed to have friends with a wide and diverse range of political beliefs, my Facebook page news feed was packed with thoughtful and sometimes divisive commentary leading up to Election Day, as I imagined yours probably was.  

When the dust started to settle, I thought it would be good timing to post a synopsis of research I've been reading on the moral and psychological differences and similarities between conservatives and liberals.  Because my interpretation of the data I reviewed led me to a conclusion that virtually all Americans who are passionate about politics embed their beliefs in sound and perhaps commendable moral principles, it was my hope that with the holiday season, the information I posted might save a few families from some heated holiday dinner arguments.

But just as I was about to post this information, tragedy ensued.  Two days ago, 20-year-old Adam Lanza used two nine millimeter handguns to murder 26 people at Sandy Hook Elementary School in Newton, Connecticut, including 20 children between six and 10 years of age.  Instantly, my Facebook news feed was centered on the tragedy.  While the majority of the posts I read expressed grief, empathy, and compassion for the victims, I noticed an instant slew of political commentary on the event from others who are passionate about their political beliefs.  

On the Left, I read comments like these:

  • "Obama please rid this country of conservative 'values' 20 kids died today in part because of those values."
  • "So this tragedy has once again shown that Americans cling to their guns and religion...Somehow I'm sure our founding fathers and Jesus would be saying you guys got it all wrong"
  • "How many mass shootings must this country endure before something is done about gun control on the Federal level?"
  •  "And people don't want tougher gun sad"

 Here's a sample of some of the commentary from friends on the Right:

St. John's Episcopal Church, near the scene of the shooting
  •  "People wonder where God was during this tragedy and blame Him for these unimaginable losses, but yet we are becoming a Godless nation. Why am I not shocked?"
  • "If more teachers were armed, maybe this tragedy wouldn't have happened."
  • "Respond in weeping with those who weep, respond in prayer, respond by searching your own heart, respond in repentance and respond in love."
  • I read several posts featuring news stories and video footage of criminals who were using guns or other weapons to harm people being thwarted by armed citizens who used guns to defend innocent lives.
  • "At the gun second amendment rights shall NOT be infringed upon."
  • "...I think the media plays a huge role...bigger than anything else! You would not have seen this 50 years ago...even 20 years ago."
  •  "When tragedy strikes, understand that a blanket anti-gun perspective also prevents many Americans from defending themselves and their loved ones."

Depending on your own political and religious beliefs, some of these comments may offend you while you may experience as reasonable responses to a tragedy that evokes strong aversive emotions within most people.  (All this is aside from the issue of whether or not it was appropriate timing to politicize a tragedy of national interest.)  I think these quotes illustrate the following about people on both sides of the aisle: (1) We care about tragedy and suffering; (2) We sometimes convert our hurt and anxiety into anger, searching for one or more scapegoats; (3) We sometimes demonize "the other side" rather than seek to understand them even if we disagree with them.

Jonathan Haidt, PhD
Social psychologist, professor, and University of Virginia researcher (and this year's keynote speaker at the annual conference of the American Mental Health Counselors Association) Jonthan Haidt, who has been described as "the world's leading expert on the science of morality," sought to better understand the moral psychology of conservatives and liberals through the lens of moral foundations theory, a pluralist moral theory that proposes that human moral reasoning can be divided into six foundations that evolved in human beings concurrent with the development of civilization:
  1. Care/Harm: Virtues of kindness, gentleness, and nurturance fostered by our ability to feel and dislike the pain of others;
  2. Fairness/Cheating: Virtues of justice, rights, autonomy that can be further divided into two types of fairness; equality and proportionality;
  3. Liberty/Oppression: Characterized by feelings of reactance and resentment people feel towards those who dominate them and restrict their liberty; a contempt for "bullies" and oppressors;
  4. Loyalty/Betrayal: Virtues of patriotism and self-sacrifice for the group;
  5. Authority/Subversion: Virtues of leadership and followership, including respect of legitimate authority and traditions;
  6. Sanctity/Degradation: Reflective of the idea that the body is a temple that should not be desecrated by immoral activities or contaminants. 
Both liberals and conservatives are often thoroughly convinced that their beliefs are the "right," "moral" or "superior" ethical beliefs, but what did Haidt and other researchers find out about the differences in how liberals and conservatives engaged in moral reasoning when they administered the Moral Foundations Questionnaire?

Arthur Brooks, PhD
  1. Liberals emphasize the Care foundation above all other moral precepts.  Conservatives also highly value this foundation, although slightly less than liberals.  However, conservative caring is somewhat different-it tends to be less focused on animals or people in other countries and more focused on sacrifice for the group (e.g. care for wounded veterans);
  2. Both liberals and conservatives care about the Fairness foundation, but there are two kinds of fairness: (1) Equality (favored by liberals); and (2) Proportionality, meaning that people are rewarded in proportion to what they contribute (favored by conservatives).  Social scientist Arthur Brooks applies these concepts in economic terms by labeling them as (1) Redistributive fairness: It is fair to equalize rewards, whereas inequality is inherently unfair (favored by liberals); and (2) Meritocratic fairness: Fairness means matching reward to merit, whereas forced equality is inherently unfair.  In other words, liberals tend to prefer that people have similar incomes even if they may be contributing to society in varying degrees, whereas conservatives accept the notion of different incomes based on what people are contributing to society, the economy, the company, etc. 
  3. Conservatives are more likely to emphasize the Loyalty, Authority, and Sanctity foundations than liberals. The Liberal emphasis on the Care Foundation results in a tendency towards universalism and away from nationalism and puts them in opposition to hierarchy, inequality, and power.  Liberals who consider themselves spiritual, however, tend to join conservatives in emphasizing the Sanctity foundation, although in different forms.  For example, spiritual liberals are more likely to visit New Age grocery stores, where they'll find a variety of products that promise to "cleanse" them of "toxins," whereas religious conservatives are more likely to refer to the "sanctity" of life, marriage, the family, etc.  Religious conservatives are more likely, in Haidt's words, to "view the body as a temple, housing a soul within, rather than as a machine to be optimized, or as a playground to be used for fun."
  4. The Liberty foundation is, essentially, owned by libertarians, a third political group that doesn't fit neatly into the conservative or liberal camps (although they are more likely to vote for Republican or third party candidates than for Democrats).  Libertarians identify with the early American political ideology known as classical liberalism.  Like contemporary American liberals, libertarians strongly emphasize civil liberties and take many "socially liberal" positions, such as support for gay marriage and the legalization of "victimless crimes," such as adult pornography, prostitution, and recreational drug use, regardless of whether they view those acts as healthy or moral.  They differ from the "Religious Right" faction of conservatives in the sense that they are more likely to be atheists or agnostics (although many prominent libertarian politicians are Christians) who abhor the use of government as a tool for imposing one's personal religious beliefs onto the public-at-large.  But like conservatives, libertarians prefer a nation with a very limited, fiscally conservative government, lower taxes, and a free market with minimal government interference.
  5. Liberals are more likely to inaccurately stereotype the moral reasoning of conservatives than vice versa.  Haidt teamed up with two other researchers, Jesse Graham and Brian Nosek, to conduct an experiment with more than 2,000 American participants in which one-third of the time participants were asked to fill out the Moral Foundations Questionnaire normally, answering only as themselves.  For the other two-thirds of the time, they were asked to complete the questionnaires as they think a "typical liberal" or "typical conservative" would respond, allowing researchers to examine stereotypes that each side held about the other.  The more liberal a respondent, the more likely he or she was to inaccurately stereotype the other side.  According to Haidt, "The biggest errors in the whole study came when liberals answered the Care and Fairness question while pretending to be conservatives."  (Read more about this experiment.)  Some of my liberal friends have accused conservatives (and libertarians) of being selfish, greedy people who only care about themselves, but in Haidt's words, "Everyone-left, right, and center-says that concerns about compassion, cruelty, fairness, and injustice are relevant to their judgments about right and wrong."  While it's true that liberals score slightly higher on empathy than conservatives, the myth of conservative selfishness is contradicted by their scores on the Care and Fairness foundations and by a series of studies suggesting that while liberals are more likely to rely on government as a means for caring for the needy, conservatives are more likely to care for the needy through personal charity (especially religious conservatives), and more likely to volunteer for charitable purposes. In other words, both liberals and conservatives care about the needy; they simply disagree on the means by which we can best provide that care.
In sum, liberals tend to favor the Care foundation above all other moral foundations, libertarians tend to favor the Liberty foundation above all others, and conservatives tend to emphasize all five moral foundations, as depicted in the graphs below:

So now that we better understand the similarities and differences in moral reasoning of conservatives and liberals, how can we have a healthier, more productive dialogue?  How can we avoid nasty arguments at family or social events or through online social networking sites like Facebook in which we say things we later regret?  

One option is to avoid discussing controversial subjects.  While this approach works for some and may be effective at keeping the peace, it also prevents people from having healthy dialogue about important subjects and from learning more about others perspectives.  It prevents us from obtaining new information that influences us to change our own positions, and sometimes these shifts are pivotal in increasing our life satisfaction.  

Perhaps this data gives us a starting point for a healthy dialogue about moral, religious, and political issues.  In addition, I think these findings can be used to help increase empathy between people who lie on varying points of the political spectrum.  We can capitalize on the two  moral foundations we all tend to share in common (Care and Fairness) rather than emphasizing the foundations we don't equally value.  Doing so can create a "launching pad" for a more constructive conversation about areas of disagreement.  

I offer the following recommendations for a healthy political or religious dialogue:
  1. Before you give your own perspective about a controversial issue, start by learning more about the other person's perspective.  Ask questions (e.g. "What do you want to be different?"  "What are you concerned about?"  "What about this is troubling to you?" "Why is this issue important to you?").
  2. When you think you have a clearer picture of the other person's perspective, summarize your understanding of his or her perspective to check in and make sure you are understanding.  In relationship counseling, I often refer to this as "mirroring."  If the other person does not think you are understanding, ask him or her to clarify and then continue mirroring until he or she agrees that you have it right.
  3. After mirroring, validate anything about the other person's perspective that you agree with or find commendable (e.g. "I really like that you're concerned about whether or not this piece of legislation is fair.  I have the same concern;" "I can see that you really care about others' suffering, and I admire your compassion.").
  4. After validating, introduce your own perspective, using "I-language" (e.g. I feel, I think, I'm concerned about, I believe, I'd prefer, etc.).
  5. Try to keep the dialogue respectful (e.g. monitor your tone of voice, avoid interrupting, avoid labeling and exaggerating, etc.).  If your notice yourself getting too upset, you can acknowledge that you are too passionate about the issue to have a respectful dialogue at the moment and can politely terminate or postpone the conversation.  You can later reflect on what was going in within you as the topic was being discussed.  In the words of Confucius, "When we see men of a contrary character, we should turn inwards and examine ourselves."
  6. Release the need to be "right" or the need for the other person to see things as you do.  Political, religious, and moral issues are controversial precisely because there are so many valid, reasonable points on both sides of the argument.  Practice accepting that others do not believe as you do and shift your attention to (a) understanding the other person's perspective; (b) attempting to help the other person to understand yours.  The goal here is understanding, not necessarily persuasion.

I can think of no better way to end this post than by sharing some of Haidt's concluding words in his book The Righteous Mind: Why Good People Are Divided by Politics and Religion: "Morality binds and blinds.  It binds us into ideological teams that fight each other as though the fate of the world depended on our side winning the battle.  It blinds us to the fact that each team is composed of good people who have something important to say...if you really want to open your mind, open your heart first.  If you can have at least one friendly interaction with a member of the 'other' group, you'll find it far easier to listen to what they're saying, and maybe even see a controversial issue in new light."


How do you score on the Moral Foundations Questionnaire?  Take the test online for free and find out!
Interested in Haidt's work?  Consider reading his book, The Righteous Mind: Why Good People Are Divided by Politics and Religion.

Sunday, November 18, 2012

How to Test, Challenge, and Replace Unhealthy Thoughts

In my last post, I introduced six cognitive distortions, or irrational thought processes, that can fuel unpleasant feelings.  Today, I'm going to show you a model that you can use to test irrational thoughts and replace them with more helpful thoughts that tend to relieve emotional distress.  

The tool I'm going to introduce is one that I often use in session with my clients and that is rooted in a concept called collaborative empiricism.  It is a process by which the client and therapist work together as if investigators or scientists to examine one of the client's thoughts and determine if it is rational or irrational.  In other words, a good cognitive therapist will not simply tell you whether or not your thoughts are rational.  Instead, the therapist will help guide you through a structured process designed to test your thoughts out.  You and your therapist will then determine whether or not the thought has withstood this test of logic.

Before I describe this test, I'd like to offer two words of caution.  First, I want to remind you that reading this post and experimenting with this tool is no substitute for therapy.  I recommend visiting a cognitive behavioral therapist to learn how to use this tool and to experience the other benefits that come from working within the context of a therapeutic relationship.  This is all the more important if you are experiencing significant emotional distress. You can locate such a therapist in your area by visiting Psychology Today's Therapy Directory, entering your zip code, and then clicking on "Cognitive Behavioral Therapy" under the heading "Treatment Orientation." Second, I'd like to caution you against using this tool to judge yourself negatively.  Remember that all human beings think irrationally every single day-it's part of the human experience.  It's okay to be imperfect.

With that disclaimer, aside, let me introduce this powerful tool.  It includes three basic steps (some of which are divided below into more detailed steps):

  1. Conduct a chain analysis (also referred to as a "functional analysis") of the event.  Map out the whole event including what happened that triggered your feeling, how you felt, what you thought about the event, and what you did to respond to it.
  2. Test the thoughts that you experienced during or after the event to determine if any of them were irrational.  If you identify any irrational thoughts, then you would move on to the third step.
  3. Revise or replace the irrational thought with a healthier, helpful, and logical thought (i.e. a rational thought).

Let me focus in greater detail on each of these three basic steps:

Step One: Conduct a Chain Analysis

  1. Describe the situation that triggered your unpleasant feeling.  This may involve a specific event, such as a driver cutting you off on the road or waking up after an unpleasant dream, but sometimes the trigger is less clear.  If you can't identify an event that triggered your feeling, then consider noticing the signs of the uncomfortable feeling to be the trigger (e.g. I noticed that my heart was beating faster and that I was feeling tense).  It is important that when you describe the situation, you avoid any interpretations, beliefs, assumptions, or conclusions.  Its best to describe the situation using specific, objective, and succinct words, like as though a reporter were describing the situation or a camera were filming it (e.g. Instead of writing, "My boss was being a jerk," you would write some something like, "My boss asked me why I was late this morning, rolled his eyes at me when I answered, and then walked away").
  2. Identify the specific names of the feelings that you experienced at the time of the triggering event (e.g. angry, anxious, depressed, frustrated, guilt, ashamed, etc.).  Try to scale how intense that feeling was at the time of the event using a scale that ranges from zero to 100.  For example, if the feeling was anger, then a score of 100 would mean that think that it would be virtually impossible for you to feel any more angry.  Typically, this would mean that your anger was so intense that you lost control, perhaps throwing things, yelling, or maybe even hitting someone or damaging property.  A score of 50 would mean that you experienced a moderate, significant, and uncomfortable anger but still felt like you had control.  A score of 10 would mean that you experienced such a mild form of anger (perhaps a minor irritation, frustration, or annoyance, for example), that you barely noticed it.
  3. Identify the physical and behavioral symptoms of the feeling.  These can include sensations in your body (e.g. increased heart rate, choking feeling in your throat, increased muscle tension, rapid breathing, nausea, trembling, etc.) or things that you did when you felt the feeling (e.g. yelled, ran away, slammed a door, threw something, called someone a name, etc.).
  4. Identify the thoughts that were running through your mind when the event happened.  This is easier said than done, and people sometimes have a difficult time with this step until they have practiced it several times with the help of a therapist.  Sometimes, it might help you to ask questions like, "Why was I feeling anxious in this situation?"  The reasons you come up with may represent the thoughts that you were having at the time of the event. 

Step Two: Test the Thoughts You Experienced During/After the Event
This test includes seven questions that you can ask yourself in order to reach a conclusion about whether the thought is logical (i.e. makes sense, is supported by evidence, and is contradicted by little or no evidence) and adaptive (i.e. helps you to function, gives you good results that you are satisfied with):

  1. Do any of these thoughts look like cognitive distortions?  Review the list of cognitive distortions I described in my previous post and decide if any of them seem to match up with your thoughts about this event.
  2. What is the evidence for and against this thought?  First, pretend that you are a prosecuting attorney and that you must convince a prudent judge and a jury of 12 reasonable people that this thought, is in fact, true beyond even a shadow of reasonable doubt.  What evidence would you bring to the table?  Identify and review each piece of evidence.  When you have run out of ideas, pretend that you are a defending attorney who must poke holes at the prosecution's argument that you previously detailed.  Your paycheck and reputation as an attorney now depend on your ability to raise a shadow of reasonable doubt that the thought is true.  Identify and review all the evidence that you can think of.  (People who are not well-trained at using this tool typically need the help of a therapist with this step.  Alternatively, a trusted family member or friend whose perspective you value may be able to help you come up with some ideas.)  Decide which side seems to have presented a stronger argument.
  3. What are some other options for how to think of this situation?  When a scientist or an investigator observes something that she can't explain, she first identifies different hypotheses, or educated guesses about what may be happening.  When it comes to questioning our thoughts, we can do the same.  You would identify every possible way of interpreting or thinking about this event that can come up with, no matter how unlikely some of these explanations might seem.
  4. What is the worst that could possibly happen from this situation?  This question is optional and is best asked when a thought seems to fit into the cognitive distortion known as Catastrophizing, meaning that you are exaggerating the negative aspect of a situation.  For example, if the triggering event involved your tire going flat, and you think, "This is horrible!  I can't handle this," then you might decide that the worst that could happen is that you will have to spend a few minutes changing your tire out on the side of the road or will have to wait for roadside assistance and that you will later have to spend some money to replace the tire.  You would then ask questions like, "Would that really be so bad?  Would I be able to stand it?  Would I survive it?  In the grand scheme of things, would I eventually be okay?" You can also ask yourself what the best case scenario would be, and what the most realistic outcome would be (typically something in between the best and worst case scenarios).
  5. What is the effect of me having this thought? Here, you would think about how this thought is affecting your emotions, choices, and behaviors.  Is it feeding strong, unpleasant feelings?  Do you like the way you handled it?  Is it giving you good or bad outcomes?  Do you like where this reasoning is taking you?  Is it hurting you or helping you?  It is improving your circumstances?  Is it holding you back in some way?
  6. What could I do about this situation?  This question helps you to pull yourself out of your feelings and thoughts about the circumstance (reactive) and shift your focus to solutions that may empower you (proactive).  You may find that some ideas pop up in your head that suggest that the situation isn't as bad as you originally thought or is much more manageable than it seemed at first.
  7. If my friend or loved one was in this situation and had this thought, what would I tell him or her?  This question pulls you out of your limited perspective for a moment and puts you in the more objective, less emotionally attached position of being a third party observer who cares about the person who is struggling.  It allows you to start considering some other perspectives.
Step Three: Revise or Replace the Irrational Thought

If the seven questions you asked yourself in Step Two lead you to the conclusion that your thought was irrational, then the next step would be to tweak that thought so that it is more rational.  Below, I'll suggest some conversions for the six cognitive distortions I outlined in my previous post.

  1. All-or-None Thinking: Consider a new thought that pulls your conclusion away from an extreme stance and into a more balanced "gray area."  For example, if you concluded that a training seminar you attended for work was "a complete and total waste of my time," you might consider a thought like, "The training wasn't as helpful as I wanted it to be, but a few things were worth hearing."
  2. Jumping to Conclusions: Rewrite the thought to be less conclusive or to raise questions instead of defaulting to assumptions.  For example, if you're driving down the road, a driver cuts you off before making a sharp turn onto a side street, and you conclude that he's a jerk, you might consider a thought like, "I have no idea what's going on with this guy, but he's not driving safe.  Maybe he's not paying attention, maybe he's experiencing an emergency, but I doubt he's intentionally trying to harm me."
  3. Magnifying or Minimizing: Revise the thought to include evidence that contradicts your initial thought.  For example, if you see a TV story about a veteran who suddenly became violent and started hurting people, and you thought something like "Veterans are dangerous, unstable people who have issues," you might replace it with a thought like "Some veterans are unstable, but now that I think of it I know of stories of veterans who are doing wonderful things for their communities, and I've only seen a small handful of stories about them doing something harmful."
  4. Personalizing or Blaming: Revise the thought so that it no longer defaults to a conclusion that is either solely about you or solely about others.  For example, if you're on the phone with an angry customer, replace thoughts like "What did I do that was so wrong?  Why is this lady being so rude?" with thoughts like "She may be angry for reasons that have little or nothing to do with me, but I also may have played a part in her anger."
  5. Imperatives: Convert the absolute statement into a personal preference or possibility.  For example, replace "I should have caught that mistake" with "I wish I'd caught that mistake, but I can't catch them all."  Similarly, a thought like "Those two should not be together" could be replaced with "I don't think those two are a very compatible."
  6. Emotional Reasoning: Accept that you are having an emotional response while acknowledging that the emotion isn't a fact and doesn't have to prove anything.  For example, if you reason "I feel guilty, so I must be doing something wrong no matter what others tell me," you can think "I know I'm feeling guilty, but that doesn't necessarily mean I'm doing something wrong."
That's it, folks!  I've presented a tool that I hope you find helpful in recognizing or replacing irrational thoughts.  A few more notes on this tool: First, the aim of this tool isn't to completely erase all unpleasant feelings.  Unpleasant feelings can be healthy and functional.  In fact, they are necessary for our survival.  Instead, the tool often reduces the intensity of unpleasant emotions so that you can think more clearly and react more intentionally.  Second, this tool will probably only be helpful if you use it repeatedly, and there are a number of tools that you can use to train yourself.  In addition to attending sessions with a Cognitive Behavioral therapist until you have mastered the process, you can use paper tools such as the Dysfunctional Thought Record or the REBT Self-Help Form.  I'm also a big fan of using smart phone apps and tablet apps.  If you enter the term "CBT" into your device's app store, you can experiment with a number of helpful tools.

Friday, November 9, 2012

Cognitive Distortions: Six Mind Games that Keep Us Unhappy

When I experience a strong, negative, or unpleasant emotion, I think of that feeling as a "red flag" that I'm thinking irrationally.  What do I mean by "irrationally?"  Irrational thoughts have two characteristics: (1) They are illogical, meaning they don't make sense, there is a relative lack of evidence to support them, and there is a relatively stronger case against them; and (2) They are maladaptive, meaning they don't help me function well in my environment--they work against me.  

All human beings think both rationally and irrationally; it's part of the human condition.  We're wired that way.  And many of these thoughts happen automatically, with little or no conscious effort on our part.  We all have our own unique cognitive filters.  We tend to filter new information about things that happen our lives through a filter of past memories and experiences.  The problem is that some of these filters skew, twist, and warp the picture to keep us feeling, thinking, and acting in unhealthy ways.

In today's post, I'm going to outline six different cognitive distortions that hinder us.  Cognitive distortions are irrational thought processes, or as some people define them, thinking errors.  Before you read on, understand that we all use these distortions.  In fact, we use them on a daily basis, even if we are relatively unaware that they're humming around in the background.  So I invite you to suspend judgment about yourself, give yourself permission to be human, and identify which of these distortions you think you tend to use the most.

1) All-or-None Thinking (a.k.a. Dichotomous Thinking, Polarized Thinking): You look at things in absolute, black and white categories, ignoring other possibilities that might lie on a spectrum somewhere in between or outside of the two categories.  (Examples: “You’re either for me or against me,” excluding other possibilities such as being neutral or having mixed thoughts or feelings for or against; or “You’re either part of the problem, or part of the solution,” excluding the possibility that someone could in some ways contribute to a problem and in other ways contribute to a solution.)

2) Jumping to Conclusions: You draw a conclusion somewhat prematurely based on very limited information.  Can include:
  • Overgeneralizing: You make a sweeping negative conclusion that goes far beyond the current situation.  (Example: “I was so lost in class today.  I can’t do math,” generalizing confusion about one particular math-related topic on one day to all math-related topics on all days.) 
  • Labeling: A variation of Overgeneralization that occurs when you apply a fixed, global, or absolute label to yourself or others, often taking the form of name-calling.  (Example: “I’m such an idiot!” after spilling a drink on the carpet, or “What a jerk” after another driver almost hits you on the road because he or she didn’t check a “blind spot” before trying to merge.)
  • Mind Reading: You believe you know what others are thinking or feeling while failing to consider other more likely possibilities.  (Example: “They don’t think I know what I’m doing” when giving a presentation you are nervous about, ignoring the possibility that others think you’re doing fine or aren’t particularly focused on evaluating you one way or the other.)
  • Catastrophizing (a.k.a. Fortune Telling, Awfulizing): You predict the future negatively and/or exaggerate the negative aspect of a situation without considering other more likely outcomes.  (Examples: “I’m going to screw this up;” “I’m going to be late, my boss will get mad, I’ll get fired, I won’t be able to pay the bills, and I’ll end up homeless!”)

3) Magnifying or Minimizing: You magnify one aspect of a situation and/or minimize other aspects.  This can include:
  • Mental Filter (a.k.a. Filtering, Selective Abstraction, Tunnel Vision, Confirmation Bias): Paying undue attention to one or a small number of pieces of information while ignoring or failing to see the whole picture.  (Example: “My presentation sucked” after receiving some constructive criticism from one or two attendees even though a dozen others gave you excellent reviews, ratings, and compliments.)
  • Disqualifying/Discounting the Positive: You unreasonably tell yourself that positive experiences, deeds, or qualities do not count (Example: “I only got a positive evaluation because my boss was being nice;” “I only met my quota because I got lucky.”)

4) Personalizing or Blaming: You believe others are behaving, thinking, acting or feeling a certain way because of you, without considering other more plausible explanations for their behavior (Personalization).  Conversely, you may blame others for your thoughts, feelings, or behaviors while overlooking ways that your own attitudes and behavior might contribute to a problem (Blaming).  (Examples: “What did I ever do to him to make him look at me that way?” “You’re making me so mad!”)

5) Imperatives (a.k.a. Shoulding/Shoulds, Must Statements, Absolutes, Dogmatic Demands): You have a list of solid, absolute, rigid, inflexible, unreasonable, or ironclad rules and assumptions about how you or others should think, feel, or act.  This distortion often contributes to perfectionism or a strong need for control.  (Example: “I have to get this right” or “You need to stop doing that.”)  Imperatives can be converted into healthier thoughts called Personal Preferences, such as “I’d like/prefer to…,” “I believe that…;” “I think…” or “I want you to …”).

6) Emotional Reasoning: You think something must be true because you “feel” (actually believe) it strongly, ignoring or discounting evidence to the contrary.  In some, it is experienced in relation to deeply held core beliefs that may connect to early developmental experiences that evoke strong emotion.  (Example: I make good grades, have won several academic honors, and score high on standardized tests, but I still feel like I’m stupid; like I’m just not good enough.)

So what do we do about cognitive distortions?  Well, you have plenty of options.  You can identify them, explore them, study them, test them, accept them, ignore them, act on them, challenge them, feed them, struggle with them, challenge them, or revise them.  The approach I favor involves the following process:
  1. Identify them while compassionately accepting that you are using them.  Avoid judging yourself for experiencing them.
  2. Test them out; explore them empirically.
  3. Depending on the outcome of #2, decide whether you'd like to replace them or simply modify them to be more helpful.
In my next post, I'll walk you through this three-step process.

List of Cognitive Distortions adapted from (1) Cognitive Therapy: Basics and Beyond by Dr. Judith Beck, (2) Feeling Good: The New Mood Therapy by Dr. David Burns, and (3) A Guide to Rational Living by Dr. Albert Ellis

Thursday, September 6, 2012

Seven Tips for More Affordable Mental Healthcare

For many Americans, access to mental healthcare is a matter of necessity, not a luxury.  And for most of us, it's not free.  Like other needs, such as food, water, clothing, and shelter, quality healthcare comes at a cost. Impoverished Americans are typically eligible for Medicaid or CHIP programs (Children's Health Insurance Programs), retirees have Medicare, and the wealthy can typically afford their care.  So that pretty much leaves middle class Americans of working age to grapple with the burden of affordable mental healthcare.  In this post, I'm offering you 7 tips for making your mental healthcare more affordable.  I hope you find them helpful.

1) If you take medication, ask about generics.  

I am surprised to find how many of my clients are unaware that many of the medications they are being prescribed are available through generic drug discount programs at major retailers, like Walmart and Target.  Some of the most commonly prescribed medications for depression, anxiety, Bipolar Disorder, and psychotic disorders are available for $4 for a 30-day supply or $10 for a 90-day supply.  For most of us, buying medications through generic drug programs is less expensive than purchasing through insurance, and for those of us without insurance, these programs are a godsend.  Ask your prescribing physician if there is a generic available for any name-brand scripts.  Make sure that your physician knows that you prefer generic medications when appropriate and that your pharmacist knows that you consent to receiving generics when they are available.  Your physician may determine that a generic medication is not the right fit for you, and many medications are not available in a generic form, but you may never know if you don't talk about it.

2) If you don't have health insurance and can't afford your medication, consider applying for a prescription assistance program.  

Many pharmaceutical companies and charitable organizations offer free or discounted medications to uninsured patients. You can apply for assistance through the Partnership for Prescription Assistance.  Fortunately, many clients I've referred to this resource over the past 7 years have been able to get help.

3) If you don't have health insurance, start shopping.  

Signed into law by President Obama on March 23, 2010, the Affordable Care Act requires most Americans to purchase health insurance beginning in 2014, a requirement known as the individual mandate.  By 2016, the penalty for noncompliance will be $695 per adult and $347.50 per child with a maximum penalty of $2,085 per family.  Purchasing health insurance is not just just a good idea; it's now the law.  Treat the purchase of health insurance just as you would any other significant investment, like a car or a home.  Comparison shop with multiple companies and plans.  An insurance agent or underwriter may be helpful in customizing a plan that works for you.  Ask friends and family members what insurance they've purchased and whether or not they're happy with their plan.  If you keep getting denied coverage because of pre-existing conditions, understand that beginning in 2014, insurance companies will be prohibited from denying coverage.  In the meantime, you can obtain insurance either through a federal pre-existing insurance plan or a state high risk pool.  

Even without a pre-existing condition, health insurance can be expensive depending on a range of factors, such as age, gender, body mass, lifestyle habits, and place of residence.  And those of us who are self-employed or whose employers don't offer a health plan miss out on three advantages of employer-based insurance plans: 
(1) We have to pay for  the entire premium ourselves instead of splitting the cost with our employer; 
(2) We can't purchase our plans with pre-taxed earnings as companies can; and 
(3) We don't get a discount for buying in bulk.  

But there are some ways to compensate for these drawbacks.  If you are the member of a professional association, see if your association works with an insurance company that offers reduced rates for members.  When I transitioned into private practice, I was afraid that I'd have to pay hundreds of dollars a month for insurance, but by going through the American Counseling Association, I found a good plan with a $1,500 deductible and a 40% coinsurance rate for just over $80 a month.  Consider a plan with a higher deductible, often known as catastrophic coverage.  These high-deductible policies may be more affordable and will generally work well for more expensive and serious medical costs, but you will have to pay for smaller expenses until you meet your deductible.  The good news is that the rate you pay for these expenses will be discounted, as the provider will bill you for the same contracted rate that your insurance company would typically pay for.  Nonetheless, the steeper your deductible, the greater the possibility that you will be paying for a lot of out-of-pocket expenses.  And that brings me to my fourth tip.

4) Put money aside each month for out-of-pocket medical expenses.
I know this is easier said than done.  Everyone plans to put some money aside, but few of us ever seem to get around to it.  I recommend that you start off by completing a household budget.  Based on the income you have left after your expenditures, decide how much money you can reasonably invest in healthcare savings.  If you don't have enough left over to invest, then the next question becomes, "What can I cut in my budget to make my health a priority?"  If I'm not saving up money for my health expenditures, but I have the newest iPhone and a premium cable plan with so many channels that I could watch a new one everyday of my life for 5 years, then I might want to question my priorities.  Think about it this way: The typical American family spends about 5% of its income on healthcare, which is a little more than half of what it spends on food, another basic necessity.  Some cost-saving measures can be as simple as making coffee at home instead of buying it at a restaurant or preparing more meals at home instead of eating out.  

If you're like me, you may need a little extra help in staying disciplined enough to put some money aside, so I'll offer three options that may help you: 

(1) If you are not self-employed, consider a flexible spending account (FSA).  FSAs allow you to put aside a little money every month to save for healthcare expenses, and since that money is pre-taxed income, you're saving on your healthcare expenses.  But be careful; FSAs operate on what's called a "use it or lose it" principle, meaning that you lose anything left over in the account by the end of the year.  For this reason, it's best to base your estimate on a typical year's worth of healthcare expenditures.  

(2) Regardless of whether or not you're self-employed, health savings accounts (HSAs) tend to be a good strategy if your insurance plan is a high deductible health plan.  Like FSAs, HSAs allow you to put aside some pre-taxed money every month for healthcare expenses.  But unlike FSAs, you don't lose money that you don't spend by the end of the year.  The bad news bout FSAs and HSAs is that the Affordable Care Act (ACA) places some significant limitations on the use of such programs.  For example, people with FSAs used to spend their remaining funds on routine over-the-counter (OTC) healthcare supplies at the end of the year to avoid losing their balance, purchasing common household items like vitamins and cold and flu medications.  But under the ACA, OTC expenditures are no longer permitted for both FSAs and HSAs.  The ACA also cuts in half the amount you are allowed to invest in FSAs from $5,000 per year to $2,500 effective in 2013.  Nonetheless, there are still many benefits to HSAs and FSAs.  

(3) If you don't have an HSA or FSA, consider creating a separate savings account just for your healthcare expenses.  You can also arrange to have money automatically transferred from your checking to savings account on a bi-weekly or monthly basis to help you stay disciplined.  Remember that healthcare is a need, not a luxury.  It may not be fun to spend money on quality care, but our challenge is to make it a priority. 

5) If you're struggling with the cost of your care, communicate with your provider.  

Few if any of us relish the idea of admitting that we're having a tough time paying our bills.  But if you talk to your providers about your difficulty, they may be able to offer help that could mean the difference between accessing appropriate care or not.  First, some practitioners offer sliding scale fees for those who genuinely lack the ability to pay the full rate.  Second, some providers offer payment plans that allow you to pay your bill in installments.  Third, some practitioners may offer you a discount if you pre-pay for services or pay at the time of your appointment.  Fourth, your provider may be able to refer you to an appropriate community resource to help you reduce your expenses.  In my area, I know of programs that will provide free psychiatric care and counseling for individuals with a limited income and no health insurance, but clients are often unaware of such resources.  Finally, some providers offer free or pro bono services in the rare event that a client is both ineligible for public assistance and realistically unable to pay even a sliding scale rate.  

Asking for help is easier said than done.  Many of us highly value our independence and autonomy.  We like to think of ourselves as self sufficient--of being able to handle our own expenses.  Consequentially, the idea of using a community resource or charitable program is an uncomfortable one.  But if it means the difference between taking care of yourself or not, then it makes sense to accept a little help.  You can always remind yourself that such help is temporary and that you can donate to a charitable program in the future when you find yourself in better circumstances as a form of compensation.

One more note on asking for help; If you are experiencing a true psychiatric emergency (i.e. suicidal thoughts or plans, thoughts of harming others), you can be admitted to an ER, an inpatient psychiatric program, or a crisis stabilization center immediately regardless of your ability to pay.  In some cases, your costs will be covered by local, state, or federal funds or by charitable funds.  In other cases, you may be billed for the services with the option of a payment plan, but the bottom line is that getting help is more important than ability to pay.  It's crucial that you get the help you need immediately.

6) Supplement your treatment with healthy lifestyle choices and therapy assignments at home.  

You can maximize your progress and minimize the potential for a costly relapse by supplementing your therapy with changes in your day-to-day behaviors.  If you're taking medication, be sure that you take it regularly and on schedule so that it can do its job.  Learn about and implement a diet that gives your body the resources it needs to preserve your mental health.  Regular exercise can stimulate mood-enhancing neurotransmitter regulation, boosting your mood.  Completing therapy homework assignments between sessions is associated with greater symptom relief, so if your therapist is giving you something to do between sessions, do your best to follow through.  And if you're not being given therapy assignments, then ask about it.  And while you're at it, ask your therapist about recommended self-help books.  Consider supplementing your therapy and self-help work with participation in a community support group, most of which are free.  If you're only relying on medication for mental health treatment, then I strongly recommend that you meet with a psychotherapist for counseling.  Study after study shows, for example, that depressed patients who participate in cognitive therapy show greater improvement.  Finally, avoid heavy alcohol consumption and the use of illicit drugs.  All substances that produce euphoria also interfere with brain chemistry, and such interference can counteract the therapeutic effects of medication, interact in harmful ways with medication, or make it difficult for your physician to assess whether or not a medication is helping.  

7) If you can't afford to see a psychiatrist, consider visiting a community mental health center (CMHC), a Psychiatric Advanced Registered Nurse Practitioner (ARNP), or a primary care physician (a.k.a. general practice, family doctor).  

CMHCs typically receive public and/or charitable funding to assist individuals with limited income who don't have health insurance.  While there are certainly exceptions, care at CMHCs may come with a few drawbacks.  CMHC providers are often less experienced, and there may be lengthy waiting lists or limits in the frequency of appointments.  You may not be able to access psychotherapy to supplement your medication maintenance, and in some cases, the CMHC may not charge you much less than you would pay for some private providers in the community who use a sliding scale.  Nonetheless, many people receive quality care at a reduced rate through CMHCs.  ARNPs who work in private practice are nurse practitioners who can prescribe medication under the supervision of a psychiatrist.  Because they receive less training and education than a psychiatrist, they sometimes charge less than a psychiatrist, and many of them are excellent providers (I refer to a local ARNP frequently).  Some primary care physicians are comfortable with prescribing mental health medication, especially in the case of milder depression and anxiety.  At the very least, they may be a good resource until you can afford to see a psychiatrist.  Some retail health clinics and convenient care clinics may prescribe common antidepressants at an affordable rate, especially if you are between insurance policies and just need a refill of a medication that's been working for you. To be clear, I generally recommend that clients work with a psychiatrist, as they are the most trained and qualified professionals who prescribed mental health medications.  But it would be dishonest for me to deny that many clients receive appropriate care through a PCP, especially in cases of common, simple, and mild mental health conditions.

The bottom line...

I can condense these 7 tips into 4 strategies for more affordable mental healthcare: (1) Communicate with your provider; (2) Supplement your treatment with healthy lifestyle choices; (3) Be an informed consumer when it comes to insurance and healthcare costs; and (4) Budget and save for out-of-pocket expenses.  I have seen all 7 of these strategies work for clients who I've personally provided care for, and I hope they can be helpful for you, too.  If you have any other tips or resources, feel free to post a comment and share them.