Sunday, December 31, 2006

Ford, Nixon, and the Decisions We Make

The death of President Gerald Ford has reopened an old debate: Should he have pardoned Nixon for the crimes he committed during the Watergate scandal? The debate has bubbled up in both the blogosphere and in the letters to the editor in most newspapers. It's not necessary for me to provide any links; the debate is everywhere. It got me thinking about decision-making and the guilt we have when our decisions go wrong.

Many of my clients come to me saying, "If only I had done X instead of Y, things would have been better." For example, "If I stayed with my old job, and not taken that new job, I wouldn't have been fired, and I'd be able to pay for my kid's college today. My kids are suffering from my bad decision."

In order to help my clients with their guilt, I teach them about the reality of decision-making. Ford's decision to pardon Nixon is an excellent example. To make the decision, Ford asked himself, "What are the most likely outcomes if I pardon Nixon, and what are the most likely outcomes if I don't? Which outcomes would serve the greater good?" Ford thought that pardoning Nixon would bring the Watergate scandal to a quick end. Nixon deserved to be punished, but resigning in disgrace was enough punishment for him. I'm sure he knew people would disagree with his decision, and that would have political consequences for him.

In contrast, Ford thought, if Nixon were to be prosecuted, the investigation, the trial, and the appeals would drag on for years. There was no guarantee that Nixon would have been convicted. This, too would have political consequences for the Republican Party. Or, if Nixon was convicted, would it be overturned on appeal? So, Ford decided to pardon Nixon, thinking this would serve the greater good.

Today, Ford's critics argue that the country needed Nixon to be tried for his crimes if the country to truly recover from Watergate. They argue that pardoning Nixon increased cynicism about government by showing the powerful were above the law. Some say that the more recent scandals stem from that cynicism. They conclude that all the problems Ford was concerned about were worth it for the country to heal.

The old admonition, "Hindsight is 20-20," is relevant here. But, even in hindsight, notice that time only goes forward. There is no way for us to go back again, and find out what would have happened if Ford hadn't pardoned Nixon. So, we don't really know "what would have happened if...."

Imagine this scenario: Ford doesn't pardon Nixon. There's a long, drawn out, O. J. Simpson-esque trial, and Nixon is found guilty. He appeals, and his conviction is overturned because the jury wasn't impartial. The prosecutor, knowing a lost cause when he sees it, doesn't try Nixon again. How much cynicism would that engender? What would happen then?

At this point in the scenario, I'm overwhelmed by the possibilities. It's impossible to know what would happen next, especially as we become more removed from the original choice. Each choice opens up new choices and new possible outcomes.

OK, so we never have any way of knowing "What would happen if...." Does that mean we can't evaluate our decisions at all? Is there anything like a good or bad decision? Is this another fuzzy-headed liberal way of avoiding consequences? No. We can evaluate our decisions, but we have to change the way we look at them.

First, let me summarize:

1. When me make decisions, we are guessing about future outcomes. We cannot know how every possible decision might turn out.

2. We can never know what would have happened if we made a different choice.

3. All we can ever know is how our choices have affected us and are affecting us. Tomorrow, things might change completely.

4. Past choices continue to affect us. They open up some choices to us and limit others.

It is therefore unrealistic to evaluate a decision as "good" or "bad". Choices don't "work out." Instead, they put us on paths. Those paths may take us to places that are more or less desirable, but until we die, those paths don't end. Instead of asking, "Did I make a good decision?" I should instead ask:

1. Did I make the decision well? Did I consider a range of possible alternatives, consider my values, consult others, and think through my decision carefully? Or, did I just jump into it without any forethought?

2. Am I happy with the path I'm on as a result of my decisions?

Notice the implications here. We can make a decision carefully, and be unhappy with where it took us. In the same way, we can make a decision impulsively, and it takes us to some very good places. Overall, though, if we make our decisions carefully, we have a better chance at being happy with the path we take.

So, when my clients ask, "How could I have been so stupid as to do that?" I teach them it's OK to say, "It seemed like a good idea at the time." Because time only goes forward, we can't go back and change our decisions. However, we can always make more decisions and find better paths for our lives.

President Ford made a decision which may have cost him the presidency. That path must have been a difficult path for him. Personally, I agreed with the choice he made, although for other reasons, I voted against him. I respect him deeply, though. Despite pardoning Nixon, Ford still restored confidence in the presidency. He did it by making other choices throughout his presidency. I'm going to miss him. After the mess Bush has made, we desperately need another Gerald Ford.

Monday, December 25, 2006

Insight and Psychotherapy

Now that Chanukah has passed, my round of parties and events has also passed. Christmas is a pretty boring day for me, so it gives me a chance to catch up on this poor, neglected blog.

There have been several good articles in the New York Times over the last few weeks. This one, entitled, "Sometimes the Why isn't Crucial," caught my attention. The author, Sally Satel, is a psychiatrist. She works in a substance abuse treatment facility and she questions the effectiveness of insight as a psychotherapeutic tool for her. She argues that explaining "why" someone drinks isn't as important as developing resources to resist urges to drink.

Developing insight is the primary vehicle of change for psychoanalysis and related therapies. Freud famously observed, "The child is the father of the man," meaning who we are today comes from our previous experiences. For these insight-based therapies, developing insight means not only explaining why someone has their problem, but also helping them get in touch with the feelings associated with it. Along with the couch, it's a stereotypical view of psychotherapy.

The public is generally unaware that arguments against insight-based therapies dates back many years. Albert Ellis has been arguing this point since the 1950's. In a more recent book titled (as only he can title it), How to Refuse to Make Yourself Miserable about Anything Yes Anything, he says (as only he can say):

Your early childhood experiences and your past conditioning did not originally make you disturbed. You did. (p.70).
Ellis argues that how we think and act in the present is what really matters. He says, speaking of his clients, "Their early thoughts and feelings did not make them anxious today. Rather, their present and continuing dogmas...were really the more direct cause of their current neurosis." (p.70; Emphasis in the the original). So, according to Ellis, we effect emotional and behavioral change by addressing current irrational beliefs, not by uncovering how the beliefs were acquired.

Ellis is not the only one. Behaviorists, such as Joseph Wolpe , also writing in the 1950's, argued that exposure to the feared stimulus was a more effective way of treating phobias than insight-based therapies. Fifty years later, and God knows how many studies, we still treat phobias with exposure-based treatments. The data is conclusive. Insight alone is at best minimally effective in treating phobias or almost any psychological dysfunction.

Satel identifies one reason why insight isn't effective. We have a tendency to distort our memories of life events in an effort to develop a coherent narrative:
What scientists call hindsight bias kicks in when we try to figure out the causal chain of events leading to the current situation. We may well come up with a tidy story but, inevitably, it will contain large swaths of revisionist history. It’s not that we bias ourselves deliberately; it happens because the mind tends to make events in the past appear comprehensible and orderly. We forget the uncertainties that might have beset us as we struggled in real time.
So, how do we develop insight based on "large swaths of revisionist history?" If we're reconstructing our past, an erroneous reconstruction would logically hinder our progress. Is insight important at all?

I think so. Insight has a limited, but important place because it helps us deal with resistance in psychotherapy. To illustrate, here are two vignettes. To guard my clients' privacy, they are composites of several past clients with a little bit of stereotyping mixed in.

First, consider a client who resists going to AA meetings. Normally, the therapist would take this as a sign the client is still denying his alcoholism. Without looking at his past, the therapist's natural tendency would be to confront the client about his denial. However, there is another issue.

The AA meetings remind the client of prayer meetings his family attended while he was a child. The religious sect that sponsored these meetings encouraged physical abuse of children, and the client is still coping with intense feelings of guilt and powerlessness stemming from this. After identifying this source of resistance do you think the client will then jump up and go to AA meetings? Of course not.

Putting the resistance into that context will do two things. It will relieve the client's guilt for not following through with clinical recommendations. Second, giving the client the right to refuse AA and still be respected will help him feel less powerless. Then, the therapist should look for other ways of working on recovery.

The second example involves cognitive therapy for a female client who is unable to trust men. She goes through cycles where she meets a man and falls deeply in love with him. Then, without reason, she becomes extremely jealous. She harasses him, checks on him, and eventually drives him away. She comes into therapy depressed and hopeless about ever having a normal relationship.

Without dealing with this in historical context, cognitive therapy would focus on changing the dysfunctional cognitions the client has about men. The therapist would probably identify the thought, "If my boyfriend were to cheat on me, it would be so awful, I couldn't survive it." Then, the therapist would challenge (a) the probability of cheating; and (b) whether or not her boyfriend's cheating would be survivable. However, each effort to challenge her beliefs is met by "Yes, but...." It is classic resistance behavior.

The "yes, but..." indicates the therapist is arousing anxiety which is itself interfering with therapy. A review of the client's history indicates she grew up in a family where the father had frequent affairs. There were chaotic arguments between the parents each time an affair was uncovered. The mother became increasingly depressed and spent most of her time in bed. After years of chaos, in which the client wound up being a parent to both her mother and her younger siblings, her parents finally divorced. Her mother remained angry and embittered for the rest of her life, insisting that all men are worthless.

So, the client's belief is closer to this: "All men are cheaters and when (not if) my boyfriend cheats on me, it will be awful! I'll turn into my mother and the rest of my life will be ruined." With this historical context, the therapist and client understand the "why" of her behavior. Without that understanding, there is no way to help the client will take the risk of changing her beliefs. The anxiety engendered by being reminded of her childhood is too great. Still, for change to happen, she needs to know that, in the present, she has the resources to deal with loss, rejection, and betrayal, without turning into her mother. Then, she can say, "It would be bad if my boyfriend cheated on me, but I can survive it. The risk is worth it, because it gives me a chance to have a happy, rewarding relationship."

In conclusion, explaining "why" has its place in therapy, but is useless by itself. Good therapy stays in the present, but uses the past as context. Even if the story is distorted, it still has value, providing meaning and motivation for change.

Wednesday, December 13, 2006

Goal-Setting and Marital Therapy

A recent article by Locke and Latham (2006) in Current Directions in Psychological Science reports on the status of goal-setting theory. I like setting goals in therapy because it's intuitive for most people. I don't have to teach them about irrational ideas, superegos, or schemas. It just makes sense to people to identify their therapeutic goals and how to achieve them. So, I was happy to hear that several obvious implications of goal-setting (e.g., the higher the goal, the better the performance--within limits) have good empirical support.

Much of the article was focused on industrial, not clinical psychology, but they made several observations that I found very relevant. In discussing the interaction of personality traits and goals, they differentiated between a learning orientation and a performance orientation:

The effects of goal setting as a state on the effects of goal orientation as a trait were studied by Seijts, Latham, Tasa, and Latham (2004). People with a learning goal orientation tend to choose tasks in which they can acquire knowledge and skill. Those with a performance goal orientation tend to avoid tasks where others may judge them unfavorably due to possible errors they might make. Hence they tend to choose easy tasks in which they can look good in the eyes of others. Seijts et al. (2004) found that a specific high learning goal (state orientation) is effective in increasing a person's performance regardless of their trait orientation. Performance is highest on a complex task, however, when people have a learning goal orientation and also set a learning goal. In short, the beneficial effect of a learning goal orientation can be attained by inducing it as a state.

If I can parse the academese (It's getting more difficult for me as I get older), this means:

1. People who value learning (a "learning goal orientation") prefer tasks where they can learn things.
2. People who value successful performance (a "performance goal orientation") avoid tasks where they might fail.
3. Performance is highest on complex tasks when the person has set a goal to learn new things and also has a learning goal orientation.

Yes, I know these three points are obvious. However, this is where things start to get interesting:

4. A person with a performance goal orientation will perform particularly badly under situations of high learning pressure.
5. We can induce a learning orientation by setting a goal to learn, rather than to perform.

Think of learning pressure as performance anxiety. When we are extremely anxious about our performance, it interferes with our functioning on goal-directed tasks. Hence, a student may go blank on a test, or a ballplayer (I'll leave out the Boston jokes) might drop an easy ground ball. There are some very good implications for marital therapy here.

When people come in for marital therapy they are in a state of crisis. Usually, they are saying to each other, "If you don't change, I'm leaving." But one of the most complex tasks I know is getting along with other people, especially a spouse. So, the overall goal in marital therapy is to improve how they relate to their spouse, but they are trying to do so under a state of extreme performance anxiety. No wonder marital therapy fails all too often.

Most of my clients don't have a learning orientation. Some have a performance orientation. Others have neither; they just kinda go along with life with very few goals (sometimes I envy them). The key point is that in marital therapy, there is a very high level of learning pressure.
So, the trick is to reduce the performance anxiety and increase the learning orientation. Here's my idea. I'll begin by saying:

In marital therapy our overall goal is to learn new ways of relating to each other. This is a difficult proposition. You only learn by trying, sometimes failing, and sometimes succeeding. Therapy can only work if you make it easy for the other person to try and to fail. Both of you will have to learn to tolerate each other's failures, without berating or attacking the other.

A lot of times one spouse is fed up. I expect that one person will object, saying, "I'm sick of being patient. If I let up on him/her, he/she won't change!" So, to show them the importance of reducing performance anxiety, I'll have the angry spouse do serial sevens while I badger them with, "Hurry up! If you don't get this right, I won't treat you, and your marriage is going to fail. It'll be all your fault because you couldn't do simple arithmetic. Come on! This is easy!" If I can get them laughing about this, it'll make the point. Setting a learning orientation and keeping the performance anxiety down should go a long way towards improving therapy. This will prove to be an interesting experiment.


Locke, E. A., Latham, G. P. (2006). New directions in goal-setting theory. Current Directions in Psychological Science, 15, 265-268.

Seijts, G.H., Latham, G.P., Tasa, K., & Latham, B.W. (2004). Goal setting and goal orientation: An integration of two different yet related literatures. Academy of Management Journal, 47, 227–239.