All posts by John pullyblank

M. Jackson Group Update – November 2020 – Stress Relief Tips

A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca).  This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field. 


The following is just in time for the US election, but gives a number of tips that are generally good for dealing with overwhelm.  His post is as follows:
The New York Times includes an article: “Stress Relief Tips to Relieve Election Anxiety” by Tara Parker-Pope.


Here are some excerpts:


[begin excerpts]
In a year of unprecedented stress, the nation collectively appears to be heading toward peak anxiety this week. People are sharing stories of stress eating, clearing their calendars (who could sit through a Zoom meeting during a time like this?) and threatening to stay in bed for a week.


<snip>


“We’ve had this unending momentum of a steady stream of stuff just going wrong since the beginning of March,” said the Rev. angel Kyodo williams, a meditation teacher and author of the book “Radical Dharma.” “The groundlessness that people feel is not really something the human body was meant to sustain over long periods of time.”


While there’s nothing you can do to speed election results or a coronavirus vaccine, you do have the power to take care of yourself. Neuroscientists, psychologists and meditation experts offered advice about the big and small things you can do to calm down. Here are 10 things you can try to release anxiety, gain perspective and gird yourself for whatever comes next.

Interrupt yourself

As you feel your anxiety level rising, try to practice “self interruption.” Go for a walk. Call a friend. Run an errand. Just move your body and become aware of your breathing.
“Interrupt yourself so you can shift your state,” said Ms. Williams. “Get your attention on something else. Focus on something that is beautiful. Get up. Move your body and really shift your position. I think people really need to move away from wherever it is they are and break the momentum.”

Focus on your feet

When you feel your stress level rising, try this quick calming exercise from Dr. Judson A. Brewer, director of research and innovation at the Mindfulness Center at Brown University:Take a moment to focus on your feet. You can do this standing or sitting, with your feet on the ground. How do they feel? Are they warm or cold? Are they tingly? Moist or dry? Wiggle your toes. Feel the soles of your feet. Feel your heels connecting with your shoes and the ground beneath you.“It’s a different way to ground yourself,” said Dr. Brewer. “Anxiety tends to be in your chest and throat. Your feet are as peripheral as you get from your anxiety zones.”

Move for 3 minutes

It just takes a short burst of exercise — three minutes to be exact — to improve your mood, said Kelly McGonigal, a health psychologist and lecturer at Stanford University whose latest book is “The Joy of Movement.” Do jumping jacks. Stand and box. Do wall push-ups. Dance.
“If you give me three minutes, it works, as long as you’re moving your body in ways that feel good to you,” said Dr. McGonigal, who suggests picking an inspiring song to get you moving. 
<snip>

Tackle a home project

Get rid of clutter, make a scrapbook, get a new comforter, hang artwork.
“It’s not frivolous to do something like declutter, organize or look around your space and think about how to make it a supportive place for you or anyone else you live with. It’s one of the ways we imagine a positive future,” said Dr. McGonigal, whose TedTalk on stress has been viewed nearly 24 million times. 
<snip>


Try five-finger breathing

This simple practice is easy to remember and is often taught to children to help them calm themselves in times of high stress. (I tried this the other day in the dentist chair, and it helped a lot!) Dr. Brewer has created a video explaining the technique, which works by engaging multiple senses at the same time and crowding out those worrying thoughts.Step 1. Hold your hand in front of you, fingers spread.Step 2. Using your index finger on the opposite hand, start tracing the outline of your extended hand, starting at the wrist, moving up the pinkie finger.Step 3. As you trace up your pinkie, breathe in. As you trace down your pinkie, breathe out. Trace up your ring finger and breathe in. Trace down your ring finger and breathe out.Step 4. Continue finger by finger until you’ve traced your entire hand. Now reverse the process and trace from your thumb back to your pinkie, making sure to inhale as you trace up, and exhale as you trace down.

Connect with nature

Spend time outside. Watch birds. Wander amid the trees. Take a fresh look at the vistas and objects around you during an “awe walk.” 
Recent research shows that consciously taking in the wonders of nature amplifies the mental health benefits of walking.
Numerous studies support the notion that spending time in nature and walking on quiet, tree-lined paths can result in meaningful improvements to mental health, and even physical changes to the brain. Nature walkers have “quieter” brains: scans show less blood flow to the part of the brain associated with rumination. 
Some research shows that even looking at pictures of nature can improve your mood. 
<snip>

Rediscover your diaphragm

Many of us are vertical breathers: When we breathe, our shoulders rise and fall, and we’re not engaging our diaphragm. To better relax, learn to be a horizontal breather. Inhale and push your belly out, which means you’re using your diaphragm. Exhale and your middle relaxes.
<snip>

Enjoy distractions

Give your mind a break by watching this cat comfort a nervous dog, or check out the jellyfish cam at the Monterey Bay Aquarium. You’ll find more fun diversions on our new interactive Election Distractor, including a digital stress ball, a virtual emotional support dog and Donald J. McNeil Jr., the Times’s infectious disease reporter, giving you optimistic news about the coronavirus vaccine.

Unleash the aromatics

Take a lavender foot bath, burn a scented candle or spritz the air with orange aromatherapy. It’s only a temporary reprieve, but it just might help get you through election night.
A study of 141 pregnant women found that rubbing or soaking feet with lavender cream significantly reduced anxiety, stress and depression. Another study of 200 dental patients found that orange or lavender aromatherapy helped them relax before treatment. Lavender baths lower cortisol levels in infants. Even antidepressants work better when combined with lavender therapy.
Why does aromatherapy, particularly lavender, appear to have a calming effect? Some research suggests that lavender reaches odor-sensitive neurons in the nose that send signals to the parts of the brain related to wakefulness and awareness.

Accept the present moment

Accepting the result of the election doesn’t mean giving up if things don’t go your way. In fact, you’ll be more effective at pursuing change if you accept the situation. “Our anxiety comes from the desire to have things be different,” said Ms. Williams. “There’s going to be the day after the election. And the day after that. We need to be present to what is, regardless of the outcome you want.”
Thinking about history and those who have faced seemingly insurmountable hardship in the past can help you gain perspective, accept current events and make plans to pursue change.
“My ancestors had to prepare themselves, over and over again, for moving toward a freedom that was nowhere in sight,” said Ms. Williams, referring to Black Americans. 
“We prepare for life as it unfolds, not our ideal image of it. That is, literally, the only path forward.”
[end excerpts]
Ken Pope

Pope & Vasquez: Ethics in Psychotherapy & Counseling: A Practical Guide, 5th Edition

Pope: Anti-Racism & Racism in Psychology as a Science, Discipline, & Profession: 57 Articles & Books (Citations + Summaries)
Pope: A Human Rights & Ethics Crisis Facing the World’s Largest Organization of Psychologists
Sometimes courage is the quiet voiceat the end of the day saying,“I will try again tomorrow.”—Mary Ann Radmacher

M. Jackson Group Update – October 2020 – 12 Tips for Happiness at Work

A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca).  This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:


The following article is addressed to those in medicine but can be adapted to most of us in other fields.


MedPage Today includes an article: “How to Be the Two-Billionth Most Important Person Who Ever Live—Vinay Prasad’s 12 tips for perfect happiness in medicine” by Vinay Prasad, MD, MPH.


Here’s the author note: “Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Evidence Harm People With Cancer.


Here are some excerpts:


[begin excerpts]


Work-life balance is elusive and everywhere. A Google search returns 1 billion results, but everyone complains they don’t have it. 


<snip>


I wish to offer 12 theses on the thorny issue.


1. Your value as a person is not linked to your career. It sounds obvious, but it’s easy to mix up. While it is wonderful to take pride in your work, and medicine naturally begins to define your identity, your value is not wedded to your job. Promotions and accolades don’t make you a better partner, child, parent, or friend, and in the end, these matter most.


2. Things you don’t want to do matter less than you think. Whether you are a practicing physician, a research scientist, or a bit of both, there are undoubtedly things you do not want to do, but feel obliged to. Attending a kill-me-now meeting, or writing a review article for the Journal No One Reads. Often, a senior person in your department asked you to do something that makes you cringe, and you feel you can’t say no. The truth is you can. People will forget faster than you imagine because others do not think about you as much as you believe they do (the universal truth of life). Corollary: If you are the boss, don’t ask people to do painful things unless they are necessary. If you get asked to write a review article for a journal no one reads, just say no — don’t delegate it to an underling.


3. Extra money is rarely worth it.
<snip>
There may, occasionally, be opportunities to make a little extra. Stay late or cover the weekend, and pick up a few extra bucks. A small honorarium to participate in a Saturday event. Money to take an extra overnight shift. These are almost never “worth it” in the long run. They rob you of downtime and the additional money is usually not enough to change anything about your life. You may pay back your loans 0.00001% faster, or have 0.00001% more in your bank account when you die.


4. It’s OK to make a career change. If you are deeply unhappy and frustrated at work, the right answer may be to do something else with your life. A busy private practice can burn you out, despite a nice paycheck. Academic life is full of politics and struggles, and the truth, which is the thing you are supposedly pursuing, may start to seem like an afterthought. It is OK to say: this isn’t for me. I am going to change. It is OK to quit — ideally in a blaze of glory — and do something else. 


<snip>


5. Some places are no good and will never be good. There are warning signs to identify no-good places that will never be good. Most folks who work there are chronically unhappy or don’t have good things to say. There is a mass exodus, which I define as more than one-fourth of people in the institution having left in a year. Leaders brag about new hires, but are silent about losing existing staff. Good people — nationally known, externally successful people — leave, and are not enticed to stay. Bad leaders spend most of their time solidifying their position, and watch as Rome crumbles. Whenever I speak to a colleague of mine who left a “sinking ship,” there is always initial discomfort — it’s hard to relocate or start anew — but gradually there is elation, and folks wonder why they didn’t leave years before.


6. If it is truly important, they will email twice. Don’t get me wrong. I aspire to be polite and punctual and responsive by email, but the truth is, inevitably, we all fall short. Don’t beat yourself up. If it is really important, the sender will email twice. 


<snip>


7. No need to answer emails after hours. A new law in France guarantees the right to not be obliged to respond to work after hours. Americans love to mock European attitudes favoring short work weeks and long vacations, but perhaps we could learn from their deliberate attempts to ensure life is full of joy and pleasure.


8. Most advances will happen without you. It is hard to hear the bitter truth that 99.99999% of us are replaceable at work, but none of us are replaceable at home. Even those of us who work on cutting-edge discoveries (or delude ourselves that we do) would do well to note that most advances in science are forced moves. It is likely in a 10- or 5- or 2-year period of time that someone working in the field will make the discovery. You, i.e., the flesh and blood that comprises your body, is rarely necessary for even Nobel Prize-winning discoveries. If you went to happy hour every Friday at 4 p.m., the discovery would still happen, probably at nearly the same time, and most likely it won’t win the Nobel.


9. If you achieve everything you want you will be the 2,245,234,235th most important person who lived; if you fail at everything you will be the 2,245,234,236th most important. Sometimes, it is valuable to view the world from the vantage of all of human history. There are few great people, whom I define as those who changed the course of civilization, for better or worse. 


<snip>


10. Don’t compare yourself to your peers. No one took your opportunity. Recently, I was speaking to a college-bound senior. He lamented that he did not get into his top-rank school, and noted that a classmate was selected. “He took my spot,” he mused. I think his statement is both technically inaccurate, and practically unhelpful. It’s technically inaccurate in the sense that college admissions is a national process, and schools are not saving a spot for any particular high school, where one student’s admission directly pushes out a classmate. Instead, the competition is national. The comment is practically unhelpful because time spent thinking of yourself as a victim is time that could be used for productively living your life.


11. When you love what you do, it isn’t work. The opposite of being willing to decline some things you don’t want to do is to acknowledge the sheer pleasure it is to be paid to do some of the things that you do. In the course of human civilization, it is a rare pleasure to wed doing something that you might otherwise do anyway with earning a living for doing it. Thinking about this, and trying to maximize it in your life, may help achieve the elusive balance.


12. Spend less time wanting to be known, and more time having something to say. The Moby Dick of academic medicine is wanting to be known — to be praised, invited, and respected. Folks go to great lengths to achieve this, including the popular technique of obsequious flattery.


<snip>


Improve yourself internally. Figure out what you have to say. What you believe in. Read more, talk less. If and when you have something to say, say it, and if it doesn’t come, then relax. Authenticity can be spotted from an airplane. We all want to escape the person who aspires to be known, but we can’t get enough of people who have something to say.


[end excerpts]


Ken Pope

Pope: Anti-Racism & Racism in Psychology as a Science, Discipline, & Profession: 57 Articles & Books (Citations + Summaries)
Pope & Vasquez: Ethics in Psychotherapy & Counseling: A Practical Guide, 5th Edition

Pope: A Human Rights & Ethics Crisis Facing the World’s Largest Organization of Psychologists
NOTE: As with any of these Psychology News List messages, please feel free to forward this message to any list or individuals who might be interested.  Thanks!

“We must picture hell as a state where everyone is perpetually concerned about his own dignity and advancement, where everyone has a grievance, and where everyone lives with the deadly serious passions of envy, self-importance, and resentment.”—C.S. Lewis (1898-1963), The Screwtape Letters (1942)
“You have reached the pinnacle of success as soon as you become uninterested in money, compliments, or publicity.”—Thomas Wolfe, novelist (1900-1938)

M. Jackson Group Update – September 2020 – The Personal Benefits of Kindness

A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca).  This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:


The Wall Street Journal includes an article: “Why Being Kind Helps You, Too—Especially Now; Research links kindness to a wealth of physical and emotional benefits. And it’s an excellent coping skill for the Covid-19 era” by Elizabeth Bernstein.


Here are some excerpts:


[begin excerpts]


Want to feel better? Be kind.


It’s a good thing to make another person feel good. But being kind—doing something to help someone else—can help you, too. Research links kindness to a wealth of physical and emotional benefits. Studies show that when people are kind, they have lower levels of stress hormones and their fight-or-flight response calms down. They’re less depressed, less lonely and happier. They have better cardiovascular health and live longer. They may be physically stronger. They’re more popular. And a soon-to-be published study found that they may even be considered better looking.


Being kind is an excellent coping skill for the Covid-19 era. In a time of isolation, kindness fosters connection to others. It helps provide purpose and meaning to our life, allowing us to put our values into practice. And it diminishes our negative thoughts.


 “Our attention isn’t something that is infinitely expansive,” says Emiliana Simon-Thomas, science director of the Greater Good Science Center at the University of California, Berkeley. “What we are feeling at any given moment is related to what we are doing, so if we are behaving kindly, that experience will occupy our emotion.”


Psychologists call kindness altruism and talk of two types: reciprocal (you help someone because it will benefit you in some way—like giving money to get a tax break) and pure (you have no expectation of reward). Humans evolved to do both. We’re not the biggest, strongest or fastest animal in the kingdom, so we needed to band together to survive. “The key to our success is not the survival of the fittest,” says Jamil Zaki, a neuroscientist and associate psychology professor at Stanford. “It’s survival of the friendliest.” 


Of course some people are kinder than others—specifically, people born with the personality trait of empathy. Yet, nature accounts for just half of our propensity to be kind, says Dr. Zaki. The rest is nurture—we learn it from our parents, our family and our community. And we can also teach ourselves. “Kindness is a skill we can strengthen, much as we would build a muscle,” says Dr. Zaki, who is the author of “The War for Kindness: Building Empathy in a Fractured World.”


Kindness can even change your brain, says Stephanie Preston, a psychology professor at the University of Michigan who studies the neural basis for empathy and altruism. When we’re kind, a part of the reward system called the nucleus accumbens activates—our brain responds the same way it would if we ate a piece of chocolate cake. In addition, when we see the response of the recipient of our kindness—when the person thanks us or smiles back—our brain releases oxytocin, the feel-good bonding hormone. This oxytocin boost makes the pleasure of the experience more lasting. 
It feels so good that the brain craves more. “It’s an upward spiral—your brain learns it’s rewarding, so it motivates you to do it again,” Dr. Preston says.


Are certain acts of kindness better than others? Yes. If you want to reap the personal benefits, “you need to be sincere,” says Sara Konrath, a psychologist and associate professor at the Indiana University Lilly Family School of Philanthropy, where she runs a research lab that studies empathy and altruism. 


It also helps to expect good results. A study published in the Journal of Positive Psychology in 2019 showed people who believed that kindness is good for them showed a greater increase in positive emotions, satisfaction with life and feelings of connection with others—as well as a greater decrease in negative emotions—than those who did not.


How can you be kind even when you may not feel like it? Make it a habit. Take stock of how you behave day to day. Are you trusting and generous? Or defensive and hostile? “Kindness is a lifestyle,” says Dr. Konrath.


Start by being kind to yourself—you’re going to burn out if you help everyone else and neglect your own needs. Remember that little acts add up: a smile, a phone call to a lonely friend, letting someone have the parking space. Understand the difference between being kind and being nice—kindness is genuinely helping or caring about someone; niceness is being polite. Don’t forget your loved ones. Kindness is not just for strangers.


And if there’s no opportunity to be kind at the moment, recall a time when you were generous or helpful. Research suggests that remembering past acts of kindness can also increase your well-being


<snip>


In reporting this column, I heard from many people who are trying to be extra kind since the pandemic started. They are taking meals to elderly neighbors, then watering their plants; mentoring teenagers stuck at home; leaving bigger tips for restaurant staff; stopping to let other drivers into traffic more often. 


Deirdre Moran posts a joke each day on the phone pole in front of her house in South Brunswick, N.J. Many are “cringeworthy,” she says. (“Can a frog jump as high as an average tent? Of course! A tent can’t jump.”) But Ms. Moran, who teaches at a local school, has seen neighbors take pictures of the jokes and once received a note reminding her that she forgot to post a new one that day.


Kat Vellos and her partner exchange gifts with their older neighbors, leaving gingerbread cookies, lemon blueberry cake and homemade granola on the fence between their homes. They’ve received lemons, herbs and tomatoes from their neighbors’ garden, an extra bag of flour, and a bouquet of flowers in return. “There are innumerable ways to share moments of connection even when you can’t get together in person,” says Ms. Vellos, a digital product designer in Berkeley, Calif.

Mary Gossman keeps a cooler of cold water and a basket of snacks at her front door for mail and delivery people. Photo: Mary Gossman

Mary Gossman keeps a table outside her front door with a cooler full of cold water and a basket of snacks for the mail and delivery people. She sometimes pays for the meal of the person behind her in line at fast-food restaurants and gives gift cards to cashiers at the grocery store. “There are so many things we can do—they don’t all have to be grand gestures,” says the retired office manager from Homestead, Fla.


<snip>


Want to Be Kinder? Here’s How.

Make it a habit. Earmark time in your schedule to help someone else. Volunteer. Donate. Call a friend. Bake for a neighbor.


Lower the bar. Kindness doesn’t have to be a big deal. Practice being kind each time you go out—smile at people and say hello. Text a friend who is struggling. Take out a neighbor’s garbage. “It can take a minute and cost nothing to change someone’s day,” says Jamil Zaki, associate psychology professor at Stanford.


Be kind to yourself. “If you try to be kind to others while being cruel to yourself, you will burn out,” Dr. Zaki says.


Make small talk. In a time of isolation, this can brighten someone’s day. Say hello. Remark on the shared experience. (“Crazy weather we’re having.”) “Just acknowledging another person’s common humanity is an act of kindness,” says Emiliana Simon-Thomas, science director of the Greater Good Science Center at the University of California, Berkeley.


Change it up. Research shows that doing a variety of kind acts makes you happier, says Sara Konrath, an associate professor at the Indiana University Lilly Family School of Philanthropy.


Remember your loved ones. Kindness isn’t just for strangers. When you’re kind to the people you live with, “everyone reports being in a better mood and having more positive emotions,” says Stephanie Preston, a professor of psychology at the University of Michigan. 


Look for role models. Emulate them.


Don’t get discouraged. Sometimes other people don’t respond in kind. This doesn’t mean they didn’t appreciate your effort. Remind yourself of another time it went well. Keep going.


Recall previous acts of kindness. Research suggests that remembering past acts of kindness also increases your well-being.


Teach your children. Model kind behavior.


Recognize others’ kindnesses. Thank them. Share on social media. It’s easy to pay attention to people who are loud and mean. Elevate the voices of people who are quiet and caring. “When we make kindness visible, we also make it contagious,” Stanford’s Dr. Zaki says.


[end excerpts]


Ken Pope

Pope: Anti-Racism & Racism in Psychology as a Science, Discipline, & Profession: 57 Articles & Books (Citations + Summaries)
Pope & Vasquez: Ethics in Psychotherapy & Counseling: A Practical Guide, 5th Edition

Pope: A Human Rights & Ethics Crisis Facing the World’s Largest Organization of Psychologists
NOTE: As with any of these Psychology News List messages, please feel free to forward this message to any list or individuals who might be interested.  Thanks!

“I expect to pass through this world but once; any good thing therefore that I can do, or any kindness that I can show to any fellow-creature, let me do it now; let me not defer or neglect it, for I shall not pass this way again.”–Stephen Grellett (1773-1855), though often attributed to a another, more famous Quaker, William Penn

M. Jackson Group Update – July 2020 – Dealing with Bullies

A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca).  This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:

The Wall Street Journal includes an article: “Why It Seems Like Bullies Are Everywhere—and How to Stop Them—Bullies try to intimidate people they see as weak or vulnerable. Here’s how to respond” by Elizabeth Bernstein.
Here are some excerpts:

[begin excerpts]
People tried to push each other around before the pandemic. But lately it seems as if the bullies are taking over. Constant fear and anxiety fuel anger. 
The move of many of our interactions online means we are having less face-to-face communication; psychologists have long known that this decreases empathy, while anonymity—or the illusion of it—makes it easier to misbehave. 

And in a time of deep polarization, the tone of public discourse has grown more antagonistic.


A bully is someone who tries to intimidate another person, often repeatedly, whom he or she sees as weak or vulnerable. According to psychologists, bullies have four personality traits—called the Dark Tetrad—that often occur together: Machiavellianism, which is a tendency to calculatedly manipulate others for your own good; psychopathy, an attribute that includes a lack of empathy and a willingness to take risks; sadism, the propensity to derive pleasure from inflicting pain on someone else; and narcissism, an obsession with self and feeling that you are better than other people.


When we think of narcissism, we think of the extreme—someone loud, blustery and grandiose, who feels superior to others and needs constant admiration. These folks typically have narcissistic personality disorder, which is a formal diagnosis in the primary handbook for diagnosing mental disorders, the DSM-5. Yet, narcissism—an excessive interest in oneself and sense of entitlement—occurs on a spectrum, and most of us have some, says Brad Bushman, a professor of communication at the Ohio State University in Columbus, who studies narcissism and aggression. Have you ever rushed into an open spot in a busy parking lot before someone else can grab it? That’s narcissism.


In a yet-to-be-published review of 26 studies on bullying, with almost 17,000 participants, Dr. Bushman and his Ph.D. student, Sophie Kjaervik, found that the more narcissism a person has, the more likely he or she is to be a bully. People who have relatively high levels of narcissism are 20% more likely to bully than those with low levels, the analysis showed.


This is because people who are very narcissistic display a trio of behaviors called the Triple E: exploitation, entitlement and empathy impairment, according to Craig Malkin, a clinical psychologist, lecturer at Harvard Medical School and author of “Rethinking Narcissism.” They exploit others, doing whatever it takes to feel special. They feel entitled, acting as if the world owes them and should bend to their will. And they lack empathy, often becoming so fixated on the need to feel special that they stop caring about the feelings of others.


These people don’t want to be told what to do. When someone tries, they lash out. “They’re trying to shore up their sense of importance,” Dr. Malkin says. “Bullies are motivated by fear—fear of feeling insecure, fear of being unconfident, fear of being exposed.” 


<snip>
How should you respond to a bully?


First, determine whether you are safe. If not, call security or the police. Document the bully’s behavior. This will help if you need evidence, and it will keep you from doubting yourself.


Do not engage. “The only winning move is not to play the game,” says Laurie Helgoe, a clinical psychologist and author of a book about narcissism called “Fragile Bully.” Engaging will encourage the bully, who will respond to feeling threatened by attacking more, she says.


Don’t let the bully take up space in your head. Try to limit how much you think or talk about the person to others. Block the bully on social media. “You’re establishing a boundary,” says Dr. Helgoe, an associate professor at Ross University School of Medicine in Bridgetown, Barbados. “You aren’t going to let the bully take over your life.”


Accept that you’re not going to change the person. Don’t blame yourself and don’t personalize the behavior. “You’re just the one in their line of fire at the moment,” says Ramani Durvasula, a clinical psychologist, professor of psychology at California State University, Los Angeles, and author of “Don’t You Know Who I Am? How to Stay Sane in an Era of Narcissism, Entitlement and Incivility.”


Imagine your reaction. Do you want to tell the bully off? Pummel him senseless? Picture all of it, including the look on the bully’s face. Just don’t act on any of this, says Dr. Malkin.


<snip>
If you must respond—if the bullying is ongoing and destructive—make sure you offer a meaningful consequence. You’ll probably need an authority—the police, a human resources department, a lawyer—to do this. “Consequences shape behavior,” says Dr. Durvasula. 


<snip>
And remember what my grandmother, who grew up on a farm in Minnesota, taught me: “Don’t get in the mud with pigs. The pigs love it. And you just get dirty.”
[end excerpts]


Ken Pope

Pope: Anti-Racism & Racism in Psychology as a Science, Discipline, & Profession: 57 Articles & Books (Citations + Summaries)
Pope & Vasquez: Ethics in Psychotherapy & Counseling: A Practical Guide, 5th Edition

Pope: A Human Rights & Ethics Crisis Facing the World’s Largest Organization of Psychologists
“A person who is brutally honest enjoys the brutality quite as much as the honesty.  Possibly more.”—R. J. Needham

M. Jackson Group Update – June 2020 – New Experiences and Happiness

A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca).  This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:

New York University issued the following news release:


New and diverse experiences linked to enhanced happiness 

New and diverse experiences are linked to enhanced happiness, and this relationship is associated with greater correlation of brain activity, new research has found. The results, which appear in the journal Nature Neuroscience, reveal a previously unknown connection between our daily physical environments and our sense of well-being.

“Our results suggest that people feel happier when they have more variety in their daily routines — when they go to novel places and have a wider array of experiences,” explains Catherine Hartley, an assistant professor in New York University’s Department of Psychology and one of the paper’s co-authors. 

“The opposite is also likely true: positive feelings may drive people to seek out these rewarding experiences more frequently.”

“Collectively, this and other studies show the beneficial consequences of environmental enrichment across species, demonstrating a connection between real-world exposure to fresh and varied experiences and increases in positive emotions,” adds co-author Aaron Heller, an assistant professor in the University of Miami’s Department of Psychology.

The researchers, who conducted the study prior to the onset of the COVID-19 pandemic, recognize that current public-health guidelines and restrictions pose limits on movement. However, they note that even small changes that introduce greater variability into the physical or mental routine — such as exercising at home, going on a walk around the block, and taking a different route to the grocery store or pharmacy — may potentially yield similar beneficial effects.

In the Nature Neuroscience paper, the researchers investigated the following question: Is diversity in humans’ daily experiences associated with more positive emotional states?

To do so, they conducted GPS tracking of participants in New York and Miami for three to four months, asking subjects by text message to report about their positive and negative emotional state during this period.

The results showed that on days when people had more variability in their physical location — visiting more locations in a day and spending proportionately equitable time across these locations — they reported feeling more positive: “happy,” “excited,” “strong,” “relaxed,” and/or “attentive.”


The scientists then sought to determine if this link between exploration and positive emotion had a connection to brain activity.

To do this, about half of the subjects returned to a laboratory and underwent MRI scans.

The MRI results showed that people for whom this effect was the strongest — those whose exposure to diverse experiences was more strongly associated with positive feeling (“affect”) — exhibited greater correlation between brain activity in the hippocampus and the striatum. These are brain regions that are associated, respectively, with the processing of novelty and reward — beneficial or subjectively positive experiences.

“These results suggest a reciprocal link between the novel and diverse experiences we have during our daily exploration of our physical environments and our subjective sense of well-being,” observes Hartley, who also has appointments at NYU’s Center for Neural Science and NYU Langone Health Neuroscience Institute.

Ken Pope

Pope & Vasquez: Ethics in Psychotherapy & Counseling: A Practical Guide, 5th Edition

Pope: A Human Rights & Ethics Crisis Facing the World’s Largest Organization of Psychologists
Pope: Telepsychology & Internet-Based Therapy—20 Sets of Professional Guidelines, Links to State Laws, & 58 Recent Articles
“The journey of discovery begins not with new vistas but with having new eyes with which to behold them.”—Proust

M. Jackson Group Update – May 2020 – Editing Your Writing II

A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca).  This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:
 
There was such a favorable response to my recent post “How to Edit Your Own Writing: Writing Is Hard, but Don’t Overlook the Difficulty—and Importance—of Editing Your Own Work Before Letting Others See It. Here’s How,” I thought I’d circulate a few others on practical steps to better writing.
 
Here’s the second in that group: “3 Ways to Make Your Writing Clearer” by Jane Rosenzweig in Harvard Business Review.
 
Here’s the author note: “Jane Rosenzweigis the Director of the Writing Center at Harvard University. She holds a B.A. from Yale University, an M.Litt. from Oxford, and an M.F.A in fiction writing from the University of Iowa Writers’ Workshop. She has been a staff editor at the Atlantic Monthly and a member of the fiction staff at the New Yorker.
 
Here are some excerpts:
 
[begin excerpts]
 
If you’re like many of the writers I work with, you may be squandering precious minutes before your deadline making relatively minor sentence-level edits — changing a word here, cutting a word there (and then putting it back). You should certainly spell-check and proofread every document before you click submit. 
 
<snip>
 
When you’re pressed for time — which, let’s face it, is most of the time — you’ll get the best results if you prioritize edits that will sharpen your message. Instead of spending those last five minutes obsessing over a single sentence, try focusing on the big picture with these three strategies:
 
1. Cut the “since the dawn of time” opening and get right to the point. 
 
Consider this opening paragraph to a budget memo:
 
Budgets are generally complicated and difficult to create because of the number of stakeholders that must be satisfied in a variety of situations. We do not have infinite resources, nor can we please everyone all the time. We must think strategically. When we consider the pros and cons of increasing spending on digital marketing, things get even more complicated. Since the data does not support increasing digital marketing, after careful review, I have concluded that we should focus on growing our sales team. 
 
Everything in this paragraph before “since the data” is a “since the dawn of time” opening because it might as well say “Since the dawn of time people have been having thoughts about budgets. Here is a general and not very illuminating overview of those thoughts. When I have sufficiently bored you, I will share my specific thoughts about this topic with you.” While writing “since the dawn of time” sentences may help you get to your main point while drafting a document, those sentences actually end up obscuring your point. Here, the point comes in the last sentence:
After careful review, I have concluded that we should grow our sales team.
 
In most cases, your readers don’t need to hear every thought anyone has ever had about your topic. They need to know what they should think about the topic right now. 
 
When you lead with your main point, you focus your reader’s attention where it belongs. 
 
Keep only the background information that’s important to your message, and cut the rest.
 
2. Turn those descriptive topic sentences into topic sentences that make claims.
 
The first or “topic” sentence of a paragraph tells readers what to expect in the rest of the paragraph. Consider the difference between these two topic sentences:
 
Descriptive topic sentence: I met with the client on Thursday.
 
Claim topic sentence: After meeting with the client on Thursday, I recommend rethinking our pitch.
 
While the descriptive version offers potentially useful information (a meeting occurred, it happened on Thursday), readers won’t know yet why these facts matter. On the other hand, the claim version of the sentence immediately focuses a reader’s attention: the meeting on Thursday matters because something that occurred in that meeting caused you to change your mind about the pitch. Now I know what I’m getting in that paragraph: I’m going to find out what we should do about the pitch and why. And you know what you have to deliver.
 
But what if you actually just want to describe something — a meeting, a conversation, a product? Even in those cases, your topic sentence should tell your readers where to focus their attention. Consider these two sentences that could begin a paragraph describing a client meeting:
 
Descriptive topic sentence: I met with the client at his office in Boston.
 
Claim topic sentence: My meeting with the client focused primarily on plans for future growth.
 
Both sentences prepare readers for a discussion of the client meeting. But after reading the descriptive version, readers only know that the meeting occurred in Boston. In contrast, the claim version clearly establishes that the meeting yielded plans for future growth. 
 
When you begin a paragraph with a claim, you teach readers what to expect — and you remind yourself what the rest of the paragraph should deliver. If you make a habit of writing claim-based topic sentences, you’ll have less editing to do in the future.
 
3. Make sure people are doing things in your sentences, unless you don’t want them to be doing things.
 
Consider the difference between these two sentences:
 
All managers should approve and submit expense reports by Friday at noon.
 
Expense reports should be approved and submitted by Friday at noon.
 
In the first sentence, we know who should do what: Managers should do the approving and submitting. In the second sentence, we know that two actions must occur, but we’re not clear on who should do what. Should the managers approve the reports but leave the submitting to team members? Or are the managers responsible for both steps? 
 
<snip>
 
You may have learned somewhere along the line that you should always use active verbs — and you could certainly solve any confusion about the chain of command for expense reports by employing active voice. 
 
<snip>
 
Next time you finish a document with a few minutes to spare, try these three strategies first. If you get in the habit of using them, you should find you won’t need to do as much last-minute editing in the future.
[end excerpts]
 
 
“Sometimes when I was starting a new story and I could not get it going…I would stand and look out over the roofs of Paris and think, “Do not worry.  You have always written before and you will write now.  All you have to do is write one true sentence.  Write the truest sentence that you know.”
—Ernest Hemmingway (1899-1961)

M. Jackson Group Update – April 2020 – Editing Your Writing

A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca).  This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:
The New York Times includes an article: “How to Edit Your Own Writing: Writing is hard, but don’t overlook the difficulty — and the importance — of editing your own work before letting others see it. Here’s how” by Harry Guinness.
 
Here are some excerpts:
 
[begin excerpts]
 
The secret to good writing is good editing. It’s what separates hastily written, randomly punctuated, incoherent rants from learned polemics and op-eds, and cringe-worthy fan fiction from a critically acclaimed novel. 
 
<snip>
 
Here’s how to start editing your own work.

Understand that what you write first is a draft

It doesn’t matter how good you think you are as a writer — the first words you put on the page are a first draft. Writing is thinking: It’s rare that you’ll know exactly what you’re going to say before you say it. At the end, you need, at the very least, to go back through the draft, tidy everything up and make sure the introduction you wrote at the start matches what you eventually said.
 
My former writing teacher, the essayist and cartoonist Timothy Kreider, explained revision to me: “One of my favorite phrases is l’esprit d’escalier, ‘the spirit of the staircase’ — meaning that experience of realizing, too late, what the perfect thing to have said at the party, in a conversation or argument or flirtation would have been.  Writing offers us one of the rare chances in life at a do-over: to get it right and say what we meant this time.  To the extent writers are able to appear any smarter or wittier than readers, it’s only because they’ve cheated by taking so much time to think up what they meant to say and refining it over days or weeks or, yes, even years, until they’ve said it as clearly and elegantly as they can.”
 
The time you put into editing, reworking and refining turns your first draft into a second — and then into a third and, if you keep at it, eventually something great.  The biggest mistake you can make as a writer is to assume that what you wrote the first time through was good enough.
 
Now, let’s look at how to do the actual editing.

Watch for common errors

Most writing mistakes are depressingly common; good writers just get better at catching them before they hit the page.  If you’re serious about improving your writing, I recommend you read “The Elements of Style” by William Strunk Jr. and E.B. White, a how-to guide on writing good, clear English and avoiding the most common mistakes.  “Politics and the English Language” by George Orwell is also worth studying if you want to avoid “ugly and inaccurate” writing.
 
Some of the things you’ll learn to watch for (and that I have to fix all the time in my own writing) are:
 
Overuse of jargon and business speak. Horrible jargon like “utilize,” “endeavor” or “communicate” — instead of “use,” “try” or “chat” — creep in when people (myself included) are trying to sound smart.  It’s the kind of writing that Orwell railed against in his essay.  All this sort of writing does is obscure the point you want to make behind false intellectualism.  As Orwell said, “Never use a long word when a short one will do.”
 
Clichés. Clichés are as common as mud but at least getting rid of them is low-hanging fruit.  If you’re not sure whether something is a cliché, it’s better to just avoid it.  
 
<snip>  
 
Clichés are stale phrases that have lost their impact and novelty through overuse.  At some point, “The grass is always greener on the other side” was a witty observation, but it’s a cliché now.  Again, Orwell said it well: “Never use a metaphor, simile, or other figure of speech which you are used to seeing in print.”  Oh, and memes very quickly become clichés — be warned.
 
The passive voice. In most cases, the subject of the sentence should be the person or thing taking action, not the thing being acted on.  For example, “This article was written by Harry” is written in the passive voice because the subject (“this article”) is the thing being acted on.  The equivalent active construction would be: “Harry wrote this article.”  Prose written in the passive voice tends to have an aloofness and passivity to it, which is why it’s generally better to write an active sentence.
 
Rambling. When you’re not quite sure what you want to say, it’s easy to ramble around a point, phrasing it in three or four different ways and then, instead of cutting them down to a single concise sentence, slapping all four together into a clunky, unclear paragraph.  A single direct sentence is almost always better than four that tease around a point.

Give your work some space

When you write something, you get very close to it.  It’s almost impossible to have the distance to edit properly straight away.  Instead, you need to step away and come back later with fresh eyes.  The longer you can leave a draft before editing it, the better. 
 
I have some essays I go back to every few months for another pass — they’re still not done yet.  For most things, though, somewhere from half an hour to two days is enough of a break that you can then edit well.  Even 10 minutes will do in a pinch for things like emails.
 
And when you sit down to edit, read your work out loud.
 
By forcing yourself to speak the words, rather than just scanning them on a computer screen, you’ll catch more problems and get a better feel for how everything flows.  If you stumble over something, your reader will probably stumble over it, too. 
 
Some writers even print out their drafts and make edits with a red pen while they read them aloud.

Cut, cut, cut

Overwriting is a bigger problem than underwriting.  It’s much more likely you’ve written too much than too little.  It’s a lot easier to throw words at a problem than to take the time to find the right ones.  As Blaise Pascal, a 17th-century writer and scientist (no, not Mark Twain) wrote in a letter, “I have made this longer than usual because I have not had time to make it shorter.”
 
The rule for most writers is, “If in doubt, cut it.”  The Pulitzer Prize-winning writer John McPhee has called the process “writing by omission.”  Novelist Sir Arthur Quiller-Couch (and not William Faulkner) exhorted, “In writing you must kill all your darlings.”  
 
This is true at every level: If a word isn’t necessary in a sentence, cut it; if a sentence isn’t necessary in a paragraph, cut it; and if a paragraph isn’t necessary, cut it, too.
 
Go through what you’ve written and look for the bits you can cut without affecting the whole — and cut them.  It will tighten the work and make everything you’re trying to say clearer.

Spend the most time on the beginning

The beginning of anything you write is the most important part.  If you can’t catch someone’s attention at the start, you won’t have a chance to hold it later.  Whether you’re writing a novel or an email, you should spend a disproportionate amount of time working on the first few sentences, paragraphs or pages.  
 
<snip>

Pay attention to structure

The structure is what your writing hangs on.  It doesn’t matter how perfectly the individual sentences are phrased if the whole thing is a nonsensical mess.  For emails and other short things, the old college favorite of a topic sentence followed by supporting paragraphs and a conclusion is hard to get wrong.  Just make sure you consider your intended audience.  A series of long, unrelenting paragraphs will discourage people from reading.  Break things up into concise points and, where necessary, insert subheads — as there are in this article.  If I’d written this without them, you would just be looking at a stark wall of text. 
 
For longer pieces, structure is something you’ll need to put a lot of work into.  Stream of consciousness writing rarely reads well and you generally don’t have the option to break up everything into short segments with subheads.  Narratives need to flow and arguments need to build.  You have to think about what you’re trying to say in each chapter, section or paragraph, and consider whether it’s working — or if that part would be better placed elsewhere.  It’s normal (and even desirable) that the structure of your work will change drastically between drafts; it’s a sign that you’re developing the piece as a whole, rather than just fixing the small problems.
 
A lot of the time when something you’ve written “just doesn’t work” for people, the structure is to blame.  They might not be able to put the problems into words, but they can feel something’s off.

Use all the resources you can

While you might not be lucky enough to have access to an editor (Hey, Alan!), there are services that can help.
 
Grammarly is a writing assistant that flags common writing, spelling and grammatical errors; it’s great for catching simple mistakes and cleaning up drafts of your work.
 
 A good thesaurus (or even Thesaurus.com) is also essential for finding just the right word. 
 
And don’t neglect a second pair of eyes: Ask relatives and friends to read over your work.  They might catch some things you missed and can tell you when something is amiss.
Editing your work is at least as important as writing it in the first place.  The tweaking, revisiting and revising is what takes something that could be good — and makes it good. 
 
[end excerpts]
 
 
 
“I don’t mind that you think slowly but I do mind that you are publishing faster than you think.”
—Wolfgang Pauli, a pioneer of quantum physics, recipient of the Nobel Prize in Physics, having been nominated by Albert Einstein (1900-1958)
John
________________________________________
John Pullyblank, Ph.D., R.Psych. (#946)
Psychologist
Managing Partner

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Rehabilitation Psychology, Assessment & Intervention
New Westminster:  (604) 540-2720
Victoria: (250) 360-1680

M. Jackson Group Update – March 2020 – Placebo and Nocebo Effects

A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca).  This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:
The new issue of New England Journal of Medicine includes an article: “Placebo and Nocebo Effects.”
 
The authors are Luana Colloca, M.D., Ph.D., and Arthur J. Barsky, M.D.
 
Here are some excerpts:
 
[begin excerpts]
 
Placebo and nocebo effects are the effects of patients’ positive and negative expectations, respectively, concerning their state of health.1,2 These effects occur in many clinical contexts, including treatment with an active agent or a placebo in clinical practice or in a clinical trial, the informed-consent process, the provision of information about medical treatments, and public health campaigns. Placebo effects cause beneficial outcomes, and nocebo effects cause harmful and dangerous outcomes.
 
Variation in the ways that patients respond to treatments and experience symptoms is partly attributable to placebo and nocebo effects.3-6 The frequency and intensity of placebo effects in clinical practice are difficult to determine, and the range of effects in experimental settings is wide.7
 
 In many double-blind clinical trials of treatments for pain8 or psychiatric disorders,9 for example, the responses to placebo are similar to the responses to active treatment, and up to 19% of adults and 26% of elderly persons taking placebos report side effects.10 
 
Furthermore, as many as one quarter of patients receiving placebo in clinical trials discontinue it because of side effects,11,12 suggesting that a nocebo effect may contribute to discontinuation of or lack of adherence to active treatments.
 
Neurobiologic Mechanisms of Placebo and Nocebo Effects
 
Placebo effects have been shown to be associated with the release of substances such as endogenous opioids,13,14 endocannabinoids,15 dopamine,16,17 oxytocin,18 and vasopressin.19 The effects of each of these substances is specific to the target system (i.e., pain, motor, or immune system) and the illness (e.g., arthritis or Parkinson’s disease). 
 
For example, dopamine release plays a role in placebo effects of treatment for Parkinson’s disease16,17 but not in placebo effects of treatment for chronic pain20 or acute pain.21
 
Exacerbation of experimentally produced pain through verbal suggestion, a nocebo effect, has been shown to be mediated by the neuropeptide cholecystokinin22 and blocked by proglumide, a mixed cholecystokinin type A and type B receptor antagonist.22,23 This type of verbally induced hyperalgesia has been associated with increased activity of the hypothalamic–pituitary–adrenal axis in healthy persons. Both hyperalgesia and hypothalamic–pituitary–adrenal hyperactivity are antagonized by the benzodiazepine diazepam, suggesting a role of anxiety in these nocebo effects. 
 
However, proglumide blocks hyperalgesia but not hypothalamic–pituitary–adrenal hyperactivity, which suggests involvement of the cholecystokinin system in the hyperalgesia component of the nocebo effect but not in the anxiety component.22 Genetic influences on placebo and nocebo effects have been linked to haplotypes of single-nucleotide polymorphisms in the dopamine, opioid, and endocannabinoid genes.24-26
 
A participant-level meta-analysis of 20 functional neuroimaging studies in 603 healthy participants indicated that placebo effects related to pain have only small effects on the functional imaging correlates of pain,27 termed “neurologic pain signature.”28 
 
Placebo effects are likely to act at the level of several brain networks that subserve affect and the influence of affect on the multidetermined subjective experience of pain. Brain and spinal cord imaging have shown that nocebo effects cause increased pain signaling from the spinal cord to the brain.29,30 In experiments that tested the response to placebo creams that were described as causing pain and were labeled as having either high or low prices, regions for pain transmission in the brain and spinal cord were activated when people expected that they would have more pain with a higher-priced treatment.29 Similarly, some experiments tested pain that was induced by heat and ameliorated by the potent opioid remifentanil; in participants who believed that remifentanil had been stopped, the hippocampus was activated and a nocebo effect blocked the therapeutic efficacy of the drug, suggesting a role of stress and memory in this effect.31
 
EXPECTATIONS, VERBAL SUGGESTION, AND FRAMING EFFECTS
 
The molecular events and neural network changes underlying placebo and nocebo effects are mediated by expectancies, or anticipated future outcomes. When expectancies are accessible consciously, they are called expectations, which can be measured and are affected by changes in perception and cognition. Expectations can be acquired in a number of ways, including prior experience of medication effects and of side effects (e.g., analgesia after taking a medication), verbal instructions (e.g., being told that a medication will reduce pain), or social observation (e.g., directly observing symptom relief in another person taking the same medication).6,32-34 
 
However, some expectancies and placebo and nocebo effects are not accessible consciously. For example, it is possible to condition an immunosuppressive response in patients who have undergone renal transplantation.35 This has been shown by administering a neutral stimulus that was previously paired with an immunosuppressive agent. Administration of the neutral stimulus alone results in a reduction in T-cell proliferation.35
 
In clinical settings, expectancies are affected by the way in which a medication is described, or “framed.” In postoperative settings, morphine administered along with the instructions “the treatment that you are about to receive is potent in relieving your pain” induced a substantially greater benefit than covert administration in which the patient was unaware of the timing of the administration.36 A direct suggestion of side effects can also become self-fulfilling. In a study involving patients taking the beta-blocker atenolol for cardiac disease and hypertension, the incidence of sexual side effects and erectile dysfunction among patients who were specifically informed of these potential side effects was 31%, as compared with an incidence of 16% among those who were not told of the side effects.37 
 
Similarly, among patients taking finasteride for benign prostatic hypertrophy, 43% of patients who were informed explicitly of the sexual side effects had side effects, as compared with 15% of those who were not informed of them.38 
 
In a study involving patients with asthma who inhaled nebulized saline and were informed that it was an allergen, approximately half the patients had dyspnea, increased airway resistance, and decreased vital capacity.39 And among persons with asthma who inhaled an active bronchoconstrictor, dyspnea and airway resistance were more severe in those who were told it was a bronchoconstrictor than in those who were told it was a bronchodilator.40
 
Furthermore, verbally induced expectancies can elicit specific symptoms such as pain,23 itchiness,22 and nausea.41 After verbal suggestion, a stimulus associated with low-intensity pain can be experienced as high-intensity pain, and tactile stimulation can be experienced as painful.23 In addition to inducing or exacerbating symptoms, negative expectations diminish the therapeutic efficacy of active medications. The effect of a topical analgesic can be blocked by falsely informing patients that the drug will worsen rather than alleviate their pain.26
 
<snip>
 
LEARNING MECHANISMS IN PLACEBO AND NOCEBO EFFECTS
 
Learning and classical conditioning play roles in both placebo and nocebo effects. There are many clinical situations in which neutral stimuli that have previously been associated with either beneficial or adverse drug effects through classical conditioning subsequently evoke the benefit or the side effects without administration of the active drug.29
 
For example, when environmental cues43 or gustatory cues44 are repetitively paired with morphine, the same cues subsequently paired with placebo rather than with morphine can produce analgesia.45 Among patients with psoriasis in whom reduced glucocorticoid doses were interspaced with placebo (so-called dose-extending placebo46), relapse rates were similar to the rates among patients who received the full dose of glucocorticoids.47 In a control group of patients who underwent the same glucocorticoid tapering regimen but without interspersed placebo, the relapse rate was three times as high as the rate in the group that received dose-extending placebo. Similar conditioned effects have been reported for the treatment of chronic insomnia48 and for amphetamine treatment in children with attention deficit–hyperactivity disorder.49
 
Prior therapeutic experiences and learning mechanisms also drive nocebo effects. 
 
Thirty percent of women undergoing chemotherapy for breast cancer have anticipatory nausea when exposed to a previously neutral environmental cue that they have come to associate with the infusions, such as traveling to the hospital, encountering the medical personnel, or entering a room that resembles the infusion room.50 
 
After repeated venipunctures, neonates cry and show pain behaviors as soon as their skin is cleansed with alcohol before the phlebotomy.51 
 
Asthma attacks can be precipitated by showing an allergen in a sealed container to patients with asthma.52 
 
A liquid with a characteristic taste and no beneficial biologic effects that is given with an active drug that has prominent side effects (e.g., a tricyclic antidepressant) can elicit those side effects when the liquid is given with a placebo.53 Visual cues such as lights and images that are paired with experimentally induced pain can subsequently trigger pain when they are provided alone.54,55
 
<snip>
 
Reports in the mass media and lay press, information obtained from the Internet, and direct exposure to others who are having symptoms all foster nocebo responses.63 For example, the rates of reported adverse effects of statins have been associated with the intensity of negative statin-related media coverage.64,65 In a particularly vivid example, negative stories in the press and on television about harmful changes in the formulation of a thyroid medication were followed by an increase by a factor of 2000 in the number of reported adverse events, and the increase occurred only in the specific symptoms featured in the publicity.66 
 
Likewise, publicity campaigns that lead community residents to mistakenly believe they have been exposed to a toxic substance or hazardous waste are followed by an increased incidence of symptoms that the residents ascribe to the supposed exposure.63,67
 
Implications of Placebo and Nocebo Effects for Research and Clinical Practice
 
It may be helpful at the outset of treatment to identify persons who are more likely to have placebo and nocebo effects. Some of the characteristics that are associated with these responses are known, but future studies could provide better empirical evidence for these features. Optimism and suggestibility do not appear to be closely associated with placebo responsiveness.68 
 
There is some evidence that among persons taking active drugs, the nocebo effect is more likely to occur in those who are more anxious,69 have a history of medically unexplained symptoms,70 or have greater psychological distress.71 Evidence of the role of sex in placebo or nocebo effects is not conclusive.62 
 
<snip>
 
The interaction between the patient and the clinician influences the likelihood of placebo effects72 and the reporting of side effects of placebos and active drugs.49 Trust in the clinician and a positive relationship, with open communication between patient and physician, have been shown to palliate symptoms. Thus, patients with common colds who perceive their clinicians as empathetic report symptoms that are less severe and of shorter duration than those of patients who do not perceive their clinicians as empathetic; patients who perceive their clinicians as empathetic also have reduced levels of objective measures of inflammation such as interleukin-8 and neutrophil counts.73 Positive expectations on the part of the clinician also play a role in the placebo effect. 
 
<snip>
 
One way to capitalize on placebo effects in a nonpaternalistic manner in order to enhance therapeutic outcomes is to describe treatments in a realistic yet positive way. Heightened expectations of a treatment benefit have been shown to increase the response to morphine, diazepam, deep-brain stimulation,36 intravenous remifentanil,31 topical lidocaine,75 complementary and integrative approaches (e.g., acupuncture76), and even surgical interventions.77
 
Exploration of the patient’s expectations can be a starting point for routinely incorporating these expectations into clinical practice. Expectations can be clinically evaluated by asking the patient to rate expectations about a benefit of treatment on a scale from 0 (no benefit) to 100 (maximum imaginable benefit).78 Helping patients to understand their expectations of elective cardiac surgery reduced disability outcomes 6 months after surgery,79 and educating patients about coping strategies before they underwent intraabdominal surgery resulted in a significant 50% reduction in postoperative pain and narcotic use.80 These framing effects can be used by providing information not only about the appropriateness of a given treatment but also about the proportion of patients who benefit from it.81 For example, patient-controlled postoperative analgesic requirements can be diminished by emphasizing the effectiveness of the medication being administered.81
 
There may be other ethically acceptable ways of capitalizing on the placebo effect in clinical practice. 
 
Some research supports the efficacy of an “open-label placebo” approach, in which the treatment effect of an active drug is enhanced by concurrently administering a placebo and informing the patient (truthfully) that the addition of a placebo has been shown to enhance the beneficial effects of active drugs.82 It may also be possible to use conditioning effects to sustain the effect of an active drug while progressively decreasing the dose by pairing the drug with a sensory cue, a conditioning process that would be particularly advantageous for drugs that are toxic or addictive.
 
In contrast, worrisome information, mistaken beliefs, pessimistic expectations, negative prior experiences, social messaging, and the therapeutic milieu can lead to side effects and can reduce the benefits of symptomatic and palliative treatments. Nonspecific side effects of active drugs (side effects that are intermittent, idiosyncratic, not dose-dependent, and not reliably reproducible) are common.83,84 Such side effects lead to nonadherence to the prescribed regimen (or drug discontinuation), substitution of another agent, or additional medications to treat the effects. Although more research is necessary to establish a definitive link, these nonspecific side effects are probably attributable to the nocebo effect.
 
Closely coupling information about side effects with information about benefits can be helpful,85 as can describing side effects in a supportive yet nondeceptive way. 
 
For example, presenting the proportion of patients who do not have the side effects, instead of the proportion of patients who do, reduces the incidence of such effects.86
 
Physicians are obligated to obtain valid informed consent from patients before administering treatment. As part of the informed-consent process, physicians are expected to provide complete information to help patients make informed decisions about treatment. 
 
All potentially dangerous and medically significant side effects must be clearly and accurately described, and patients are instructed to report all side effects. Since enumerating benign, nonspecific side effects that are not of medical concern makes them more likely to occur, however, physicians face a dilemma. 
 
One potential solution is to educate patients about the nocebo effect and then ask whether, in light of that effect, they wish to be informed of the benign, nonspecific side effects of a treatment. This approach has been termed “contextualized informed consent”87 and “authorized concealment.”84
 
Since mistaken beliefs, worrisome expectations, and prior negative medication experiences can produce nocebo effects, exploring them with patients may be helpful. What prior bothersome or dangerous side effects have they had? What worried them about the side effects? If they are currently troubled by benign side effects, what do they presume is the significance of the side effects? Does the patient expect them to worsen over time? Answers to these questions may enable the physician to allay the patient’s concern about a side effect, thereby making it more tolerable. Reassurance that a side effect may be bothersome but is not harmful or medically dangerous may relieve the anxiety that is contributing to it. Conversely, patient–clinician interactions that fail to assuage the patient’s anxiety, or that even heighten it, amplify side effects. A qualitative review of experimental and clinical studies has suggested that negative nonverbal behaviors and a cold communication style (e.g., not making empathetic remarks, not making eye contact with the patient, speaking in a monotone, and not smiling) contribute to nocebo effects, lead to lower pain tolerance, and diminish placebo effects.88 Putative side effects often turn out to be preexisting symptoms that were ignored or dismissed and that have now been attributed to the drug. Correcting this misattribution can make the drug more tolerable.
 
Reported side effects can be a covert, nonverbal expression of doubts, reservations, or anxiety about the medication, the regimen, or the doctor’s expertise.2 Side effects provide a less embarrassing and more acceptable reason for discontinuing a medication than explicitly confronting the clinician with misgivings. In these situations, elucidating and openly discussing the patient’s concerns may prevent drug discontinuation or nonadherence to the treatment regimen.
[end excerpts]
“We used to think that if we knew one, we knew two, because one and one are two.  We are finding that we must learn a great deal more about ‘and.'”
—Sir Arthur Eddington (1882-1944)

M. Jackson Group Update – February 2020 – “It’s All in Your Head”

A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca).  This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:
JAMA: Neurology includes an article: ““It’s All in Your Head”—Medicine’s Silent Epidemic.”
 
The author is Matthew J. Burke, MD, FRCPC, of the Division of Cognitive Neurology, Department of Neurology, Harvard Medical School, & Department of Psychiatry, Hurvitz Brain Sciences Program, University of Toronto.
 
Here are some excerpts:
 
[begin excerpts]
 
It’s all in your head” is a phrase sometimes said by physicians to patients presenting with symptoms unexplained by medical disease. 
 
As a neurologist specializing in neuropsychiatry, nothing bothers me more than overhearing medical colleagues proclaim this one-liner at the bedside or snicker about these patients during rounds. 
 
Unbeknownst to them, I also hear my patients’ version of being on the other end of this phrase and find myself constantly trying to repair the damage that these words can cause. Whether physicians like to admit it or not, medically unexplained symptoms encompass a vast terrain of clinical practice. In neurology, these symptoms fall under functional neurological disorder, but every specialty has their own variants and favored terminologies (eg, chronic fatigue syndrome, fibromyalgia). 
 
The inadequate management of this segment of medicine represents a silent epidemic that is slowly eroding patient-physician relationships, perpetuating unnecessary disability, and straining health care resources.
 
The irony of “it’s all in your head” is that although this phrase is often used inappropriately and dismissively, it is technically correct. The problem does indeed lie within the head. More specifically, it lies within the brain and its complex networks that we are just beginning to understand. Over the past 10 years, neuroimaging research studies have consistently identified brain abnormalities in patients with medically unexplained symptoms—yes, biologically based changes in the activity and connections of brain regions, such as the amygdala, prefrontal cortex, temporal-parietal junction, and other structures.1 
 
These brain circuit abnormalities provide physiological explanations for once mysterious links between regions implicated in emotional processing and the generation of “physical” symptoms (eg, pain, fatigue, weakness). Jean-Martin Charcot, MD, a famous 19th century French neurologist and early pioneer of this field, reportedly insisted that a “functional lesion” would be found when microscopes were sufficiently powerful.2 Well, our microscopes are getting better, and we are now starting to see evidence of the predicted functional or software disruptions in the brain. We still do not fully understand what causes these software problems; however, recent research suggests a multifactorial etiology, including genetic predisposition, environmental risk factors (eg, childhood adverse events), and psychological stressors.3
 
Despite the growing scientific literature, there has been minimal shift in physician attitudes toward these patients. Physicians seem quite comfortable with the idea of structural brain lesions causing psychological symptoms, such as a frontal lobe stroke causing depression or a temporal lobe tumor causing delusions. However, the reverse causality of psychological factors (borne of the same substrates—neurotransmitters, neurons, and synaptic connections) leading to neurological or systemic symptoms is often hastily dismissed and remains highly stigmatized. Thus, many physicians either simply ignore these kinds of symptoms or wrongfully assume that patients are malingering.
 
Based on such attitudes, a typical physician-patient interaction may proceed as follows: (1) the physician provides a rundown of normal investigations, (2) the patient is told they have no known medical diagnoses, (3) a brief awkward exchange occurs, and (4) little further explanation, guidance, resources, or facilitation of an appropriate referral process is given. Even if the infamous phrase is not explicitly stated, this sequence leaves the patient to infer for themselves that it must be all in their head. 
 
Unfortunately, they do not perceive this as, “I have a real dysfunction of networks in my brain,” but instead understandably conclude that, “they think I’m crazy” or “faking it.”4 Sometimes, patients may hear the distant utterance of, “Maybe you should see a psychiatrist,” as they exit the office door, but in this context, such advice is rarely productive.
 
Many of these patients can be so offended by this encounter that they quickly seek multiple second opinions and subsequent rounds of pricey and unnecessary investigations. Depending on the jurisdiction and medical record system, the original physician may be completely unaware of these additional rounds of care. Mounting negative and invalidating clinical interactions can become a source of distress and cause medical trauma. At this point, patients often either fall through the cracks or stumble on a fringe medical specialist or alternative medicine practitioner who may offer the “physical” diagnosis they’ve been yearning for. This could include a growing list of unsubstantiated metabolic deficiencies, infectious disorders, or autoimmune hypersensitivities. Anecdotally, the most common current example seems to be the diagnosis of chronic Lyme disease by unvalidated assays.5 Let me be clear that many of these practitioners are well intentioned and can offer holistic approaches that medicine could learn a lot from. However, there appears to be a subset that take advantage of these patients’ desire for a “physical” diagnosis and exploit their vulnerabilities.
 
For the patient, receiving such a concrete, “organic” diagnosis often quells mounting anxiety, which in itself could be partially therapeutic. However, now wedded to their given diagnosis with no knowledge of their actual software problem, patients do not see a need to address underlying factors that may be contributing to their disorder nor do they receive the multidisciplinary care that they may so badly need. 
 
The saddest part of this epidemic is that if addressed early, these symptoms may be reversible; however, with delays to proper diagnosis and management, prognosis worsens considerably.6
 
<snip>
 
I see firsthand the high patient volumes and health care resource utilization that currently escape record keeping. I raise these concerns to my colleagues, who wholeheartedly agree, but the conversation ends there and the silence continues. I am hopeful that new research technologies, such as natural language processing, could identify these patients in medical records despite the lack of adequate billing code data and that improved records systems will better track these patients through different health care pathways.
 
To address the epidemic itself, we desperately need more clinicians and researchers dedicated to interrogating the complex interfaces of mind, brain, and health. Currently, there are small pockets in different specialties, but these are not nearly commensurate with the volume and impact of these disorders. 
 
Second, and arguably more importantly, we need to fundamentally change the culture within the medical community to eliminate the negative connotations associated with these disorders. This change requires buy-in from hospital and health care leadership and a supportive infrastructure. 
 
These patients have complex conditions and require additional upfront consultation time, resources, and collaborative care. To prevent the cycles described previously, physicians need to be incentivized to take the time necessary to optimize the initial patient encounter. 
 
This includes delivering and explaining the diagnosis in a transparent and supportive context,9 providing patient-friendly resources (eg, https://www.neurosymptoms.org/), and referring appropriately for interdisciplinary management (eg, physical therapy, occupational therapy, psychotherapy). New educational and training initiatives across medical and allied health professions will be critical for enabling a successful transition.
[end excerpts]
 
“For all those that have to fight for the respect that everyone else is given without question.” 
―Nora K. Jemisin, Psychologist & Science-Fiction Author; 1st African-American to Win a Hugo Award for Best Novel

M. Jackson Group Update – January 2020 – Dealing with Procrastination

A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca).  This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:
The Wall Street Journal includes an article: “New Ways to Battle Procrastination; As digital distractions proliferate, psychologists are coming up with new strategies—and early studies show promise” by Andrea Petersen.
 
Here are some excerpts:
 
[begin excerpts]
 
As digital distractions proliferate, psychologists are adapting tactics from cognitive behavioral therapy to target procrastination. They are also developing smartphone apps to reinforce thoughts of industriousness and weaken the allure of procrastination. While therapists and productivity gurus have long offered techniques to prod people into action, these new approaches are being subjected to more rigorous scientific study—with promising early results.
 
The efforts come as some researchers believe that procrastination is on the rise. The fault partly lies with the endless supply of distractions we carry around in our smartphones, carefully targeted to our tastes, says Piers Steel, a professor at the University of Calgary and the author of “The Procrastination Equation.” “All those beautiful AI algorithms are pushing the next most addictive thing it can think of in front of your nose. How could we do anything but procrastinate?” he says.
 
<snip>
 
Studies have found that between 15% and 20% of American adults chronically procrastinate. 
 
Among college students, the numbers are markedly higher: About three-quarters consider themselves procrastinators and nearly half say their procrastination is chronic and problematic. 
 
Procrastination can cause stress and wreak havoc on people’s work and relationships. It is also linked to mental health issues: People who procrastinate are more likely to have anxiety disorders and depression.
 
<snip>
 
Alexander Rozental, a psychologist and postdoctoral researcher at Karolinska Institutet in Stockholm, has developed a treatment for procrastination—it can be delivered online or in person by a therapist—that is based on the principles of cognitive behavioral therapy, an approach that focuses on changing the thoughts and behaviors that drive peoples’ distress. 
 
Here are its core components:
 
Revamp Your Goals
 
Goals need to be specific and scheduled. “Instead of saying, ‘Next week I’ll start studying for my exam,’ say, ‘On Monday between 9 and 11, I’ll start studying for my exam,’ ” Dr. Rozental says. Since motivation increases the closer you get to a deadline, larger goals should be divided into smaller subgoals. Then schedule regular rewards when you meet those subgoals, such as a cup of coffee or a quick walk after two hours of work. 
 
<snip>
 
Start Small, But Start
 
For procrastinators, the first step is often the hardest. They wait for a burst of motivation or inspiration that often doesn’t arrive. To overcome the resistance to beginning a project, Dr. Rozental has people start very small. “If it is hard to start with reading one page, start with reading one paragraph. If it is hard to start cleaning your kitchen, clean one cupboard,” he says. “Usually people say, ‘It wasn’t as bad as I thought, I can continue.’ ”
 
Eliminate Distractions
 
This seems like a no-brainer, but remove everything that isn’t important for the task at hand.
 
Assess Your Values
 
Dr. Rozental has participants identify their core values to help them see the relationship between the tasks they are putting off and their larger life purpose. 
 
A college student who is failing to complete an assignment may be able to find some motivation by connecting to her desire to help people as the doctor she hopes to become. You can see the “value of doing something that is very boring because it helps get you closer to the things that you value in life,” Dr. Rozental says.
 
<snip>
 
In a study published in 2015 in the Journal of Consulting and Clinical Psychology that involved 150 procrastinators, those who did the online treatment, either on their own or with the guidance of a therapist, saw statistically significant improvement on a scale of procrastination, compared with a control group. (And, yes, the procrastinators actually did the treatment.)
 
Other researchers are experimenting with game-like programs. Dr. Lukas has developed a smartphone app treatment for procrastination. Users are presented with a series of images of procrastination, such as a person reclined in a lounge chair, feet up, with a glass of beer. They are also shown pictures of industriousness, like a stack of papers with a highlighter and pen at the ready. The pictures include corresponding statements. Users are instructed to physically push images of procrastination away via a swipe upward and draw the images of industriousness closer via a swipe down. “It is very much like Tinder,” says Dr. Lukas. Images shrink as they are pushed away and grow as they are brought closer. Participants earn stars for correct responses.
 
Dr. Lukas says the technique, which is a component of cognitive bias modification, helps to override the automatic thoughts that drive procrastination (“This is boring—I’d rather be hanging out with friends”) and replace them with healthier thoughts (“I’m going to finish my assignment”).
 
“We break up these automatic routes that are dysfunctional. You start to reflect on what you do automatically and think, ‘I probably should be doing something else,’ ” says Dr. Lukas.
 
In a small pilot study published in 2017 in the journal Internet Interventions involving 31 procrastinators, those who used the smartphone app for two weeks (for an average of about five minutes a day) and also received two sessions of in-person group counseling had a statistically significant greater drop in their scores on a measure of procrastination, compared with a control group. Dr. Lukas and colleagues have formed a company, mentalis, to sell the smartphone app to consumers.
 
Dr. Steel says that the most important thing you can do to combat procrastination is to get enough sleep. “When your energy levels are down, your willpower is weak,” he says.
 
Robert Schachter, an assistant clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York, says he has identified 20 different reasons for procrastination (being a perfectionist and being impulsive are two), with each type needing a tailored treatment.
 
Since procrastination can be a feature of ADHD and depression, he screens people for those disorders.
 
He has patients write a list of the personal costs of their procrastination (paying more for last-minute plane tickets, for example) and a list of the pros of procrastination (videogames are fun, for instance). 
 
“If in fact they say the negatives really outweigh the positives, they’ll really want to do something about it,” says Dr. Schachter, who also runs the Procrastination Centers of America. Dr. Schachter had planned to open a series of centers around the country, but now the only center is his own private practice. There just wasn’t the demand, he says. “People don’t really want to fix it.”
 
[end excerpts]
 
“Knowing is not enough; we must apply.  Willing is not enough; we must do.”
(“Es ist nicht genug, zu wissen, man muss auch anwenden; es ist nicht genug, zu wollen, man muss auch tun.”)
—Johann Wolfgang von Goethe in Wilhelm Meisters Wanderjahre (1821)