psychotherapy podcast

How to Help Patients With Sexual Abuse

On today’s episode of the podcast, I interview Ginger Simonton, a PhD student finishing her dissertation. We will cover her in-depth research on alleviating the symptomology of childhood sexual abuse.

We will specifically be talking about the link between women who have been sexually abused, never given a chance to heal, and how it has affected their mental and physical health, and programs that can benefit them.

What is childhood sexual abuse?

“The CDC defines the act of CSA as “inducing or coercing a child to engage in sexual acts” that include “fondling, penetration, and exposing a child to other sexual activities” (2017).”

The facts:

  • 88% of sexual abuse cases happen with someone the child knows (Finkelhor, Ormrod, Turner, & Hamby, 2005)

  • 20-30% of women experience some form of sexual abuse before they reach 18 years old (Pereda et al., 2009; Stoltenborgh, Van Ijzendoorn, Euser, Bakermans-Kranenburg, 2011; Bolen & Scannapieco, 1999; Holmes & Slap, 1998; Finkelhor, 1994)

  • 20-40% of survivors have no adverse effects later in life (resilience is the norm) (Paras, Murad, Chen, Goranson, Sattler, Colbenson, Elamin, Seime, Prokop, & Zirakzadeh, 2009)

How does it affect health?

Statistics show that 20-40% of survivors have no negative effects later in life. This is dependent on the response of caregivers. If someone was supported, protected, validated and responded to in a therapeutic way, the child has a higher chance of resiliency, which occurs through secure attachment. If the child has secure attachment, they can usually move forward with their lives.

What Simonton’s study shows is that women who were silenced, shamed or not given a voice to resolve those childhood sexual trauma issues have more mental and physical health issues than normal. If a woman was in a multi-dimensionally unstable family—drug use, no structural stability, alcoholism, revictimization—they are less likely to have resiliency.

Bodily representations of chronic stress:

Women who experienced childhood sexual abuse that was never recognized by a loving caregiver demonstrate biopsychosocial health problems both in childhood and later on in life. Sexual abuse causes intensive stress, and there are many subsequent health issues that stem from it.

What we see is the body begin to break down in the face of cortisol and other stress-related hormones that are released over years of unresolved trauma. One of the first indicators that drives them to seek medical help is usually a physical ailment. Often the patient experiences a few health issues, and ends up medicating the physical things, but the underlying cause is never treated.

These show up in many different ways, but there are some predominant issues such as:

  • Migraines

  • Bladder problems

  • Hypertension

  • Anxiety

  • PTSD

  • Depression

  • Chronic fatigue

  • TMJ

  • Irritable bowel

  • Fibromialgia

  • Non-epileptic seizures

  • Diabetes (chronic stress makes it more difficult to control)

If your patient does have a chronic illness, that does not mean they have experienced childhood sexual trauma. However, if they are retaining stress from childhood sexual abuse, they are more likely to develop comorbid mental and physical health issues later on.

Helping patients who have experienced sexual abuse

Because we are meaning-making creatures, we assign values to situations in our lives. If something good happens, we assign positive meanings to it—we are good people, we are highly valued, we are loved, etc. If something bad happens, we assign meaning to it—we are gross, we are worthless, we are disgusting. As we internalize these beliefs, we begin to act according to those meanings in ways that further damage our bodies and minds.

So how do we help our patients revisit the meaning they’ve assigned to these traumatic experiences? Simonton’s research shows different programs and therapies that can help patients cope with the trauma and relief their symptomology.

Ask them their story

It’s important for a patient to feel they are revealing their story slowly and gradually if that’s what makes them most comfortable. Simply asking for them to tell their story, then helping them unpack the information if they mention sexual abuse, is the best way to go about it.


Don’t lead the witness

Some therapists who have been sexually abused themselves, or who are particularly drawn to sexual abuse victims, can tend to transfer other patient’s experiences and make conclusions about patients who maybe have not experienced sexual abuse. If this is the case, the therapist can sometimes “lead the witness” by suggesting and leading the patient to believe they have experienced this when they have not.

Get the right team around them

It takes a good team to help someone recover from the trauma of sexual abuse. A good friend and family support group, plus therapists and internal medicine doctors (if the patient is on medications for their comorbid physical ailments) will all bolster the patient’s healing process. As a therapist, try to work with the patient’s internal medicine doctor to get a complete picture of the patient’s whole health. That way, as the patient heals, their medication can be managed accordingly.

Family involvement is critical to patients improving quality of life. Women who had a partner or sibling did much better and received the fullest benefit of having someone with them for home care and help. Also, someone with a spiritual base or community demonstrated higher health quality of life throughout intake and therapy.

Having someone with the patient who can be there day in and day out leads to a much higher success rate than when they have isolated experiences with the therapist. What is difficult is when a person experiences positive change in their therapy, but goes back to a rigid family who relates mostly to the patient’s illness. Illness can even create a continuing underlying family rule of keeping the victim in her lower, negatively associated role.

This also helps the women establish a new relationship with whoever they bring to therapy with them in a sexual abuse program—it helps them re-relate to a person in a new healthy way. They are no longer just the victim, they can portray new goals for healing and see rapid growth alongside their partner, family or sibling.

Get them back in touch with their bodies

Many people who experience sexual abuse learn that their body is their enemy, a conduit of pain. They learn to dissociate to be able to survive, and that ability carries over into adulthood. Dissociation is a powerful tool that helps them be able to mentally “leave” their body so they can withstand physical pain or trauma.

One fascinating note Simonton made is that patients never recounted physical pain when they talked about their trauma. Their minds were so disconnected from their bodies that they had no memory of the physical consequences. Women who do this have been carrying this unchartered territory of pain in their physical bodies for so long that by the time they reach adulthood, they have to learn to reconnect with their bodies.

When we start to break the meaning apart to help patients begin to heal, we have to very delicately focus on what it means to reconnect their mind and body.

Getting patients refocused on their bodies and unearthing the resident trauma that is causing the stress-related illnesses will help them unlock their emotional and mental healing processes. They have an opportunity to discover that their body has a story to tell. By reconnecting to their bodies, they give it a voice to process its trauma.

How to listen well

There are a few things you can do to make sure your patient feels heard and validated when they open up about their sexual abuse. “Witnessing” is an important one. Some people who’ve experienced sexual abuse have stories that were never heard or validated.

When someone shares a trauma story and it is not validated (shame and silencing might have occurred with their family) it can re-damage the patient. When they share and feel validated, it can be a healing experience for them.

Asking them how it makes their body feel when they share about their experience is also important. It connects the somatic representations with the emotions and thoughts, which is important because these patients have most likely dissociated from their emotions and bodily sensations in general, but more so when they talk about their experiences.

How to listen, empathize and not take on the emotional repercussions of trauma

Hearing stories of trauma is difficult as an empathic therapist.

  • Make sure you practice what you preach—have your own therapist to help when you need it.

  • Find a colleague who also helps people through childhood sexual abuse and go speak to them about your feelings.

  • Determine a way you can take care of yourself when you get home from your work day. Create a space where you can enjoy your family, spirituality and recreation (including cardio and strength training).

  • Develop a treatment team of colleagues that works together to process through the difficult stories you are each hearing.

  • Ask fellow therapists how they feel—check in with your coworkers and fellow therapists to make sure you are each sustaining your own health.

What therapy techniques work best for the sexually abused?

  • EFT - Emotionally focused therapy for couples is an effective, research based spousal support therapy system. This teaches the spouses to be effective witnesses in the trauma story and is able to bring the support to inside of their home.

  • DBT - Dialectical behavioral therapy is incredibly helpful for people who are struggling with PTSD related to childhood sexual abuse.

  • Transference Focused Psychotherapy

  • Mentalization Based Psychotherapy

How can you tell what patients should be in regular, weekly therapy versus an intensive outpatient therapy for sexual abuse?

Many excellent outpatient therapists are doing a great job at treating patients who have experienced childhood sexual abuse. There are a few specific factors that could mean your patient would be better treated in a more intensive outpatient programs, such as:

  • If they are in a multi dimensionally unstable family where their health is being impaired. (AKA If they do not have a support system at home.)

  • If they are medically fragile because the body is beginning to break down.

    • Some outpatient programs have internal medicine staff to ensure the patients who are medically fragile are being physically supported.

  • If your patient doesn’t seem to be thriving or processing well, recommend them to an intensive outpatient program, with the idea that when they become more stable, they will titrate down to weekly therapy again.

  • If the patient is on so many medications, recreational drugs or alcohol that it puts them in a dissociative state where they are unable to concentrate and do deeper therapy work, an outpatient program might help support them while they come off of medications and process the difficulty of their trauma. (Many therapists don’t realize how much medications can dull the mind and make therapy very difficult.)

    • After a few weeks, some patients may need to be detoxed before they can fully process the emotional trauma.

During supportive forms of therapy, who should the patient bring with them to be a support?

The family is not always the most supportive group for the patient. There could be a partner or friend who is therapeutic and non-judgemental enough. However, it’s important to encourage the patient to bring someone they feel completely safe around. This person is supposed to help the patient grow and move forward, to make good choices outside of the therapy office. This person must have the best interest of the patient in mind, and not prefer the old maladaptive patterns the patient was in. They must support the patient in their growth and journey of health.

Many patients end up in relationships that are similar to the dysfunction of their trauma. How do you encourage a patient to find or make a friend that is healthy and can support them?

  • Help the patient identify their feedback loops, through identifying their early narratives and early meaning-making experiences.

  • Start to make changes as to how the person sees themself so that they see themselves as worthy. This is the best way to have lasting effects on their relational patterns.

  • A victim is a victim because they have a perpetrator. If there is no longer a perpetrator because they’ve surrounded themselves with healthy people, the patient is able to shed the victim narrative.

From chronic pain to thriving

We have found that patients who receive therapy are able to reduce the negative biopsychosocial effects. They are getting back to school, getting new jobs or raises at work, setting new goals.

Some people get stuck and lose hope, they don’t see it’s possible. Eventually though, if they keep seeking help, they are able to have breakthroughs and change their lives.

If you’re interested in learning more, here are a few podcasts and articles about emotional trauma:

How to Treat Emotional Trauma

How to Fix Emotional Detachment

Emotional Shutdown - Understanding Polyvagal Theory

***If you have been sexually abused, or think you have been sexually abused, connect with a therapist who specializes in this.


The science behind forgiveness and how it affects our mental health

What is forgiveness?

On this week’s episode of the podcast, I talk about the power of forgiveness. It’s scientifically proven that forgiveness can affect our health. As mental health professionals, this has important impacts both personally and professionally. I have also included a downloadable PDF for you to give your patients to help you walk them through the act of forgiving.

As a therapist, when I say the word “forgiveness,” my patients can shut down if I don’t explain it properly. Why? Because just the need for forgiveness is proof that they have been wronged. When we are wronged, it can be hard to let go of that hurt. That’s why I wanted to start out by saying what forgiveness (and this episode) is not about.

Forgiveness is not:

  • It is not approving.

  • It is not excusing the action, denying it, or overlooking it.

  • It is not just moving on (particularly not with cold indifference).

  • It is not forgetting or pretending it did not occur.

  • It is not justifying or letting go of possibly needed justice.

  • It is not calming down.

  • It is not a bargain or negotiation.

  • It is more than ceasing to be angry.

  • It is more than being neutral towards the other.

  • It is more than making oneself feel good.

  • It is one step towards reconciliation, but it is different from reconciliation, which requires a sincere apology from all parties.  

  • It is not dependent on the one you forgive—that would give the other power to control you by keeping you in your bitterness. Consider Corrie Ten Boom, who forgave the Nazis after losing her family in the Holocaust, or Marietta Jaeger who, after her daughter was kidnapped and brutally murdered, was able to forgive. People can forgive, even when the person who wronged them is unknown or dead.

  • It is not a one time event, but may need to be repeated (sometimes the hurt comes back, sometimes you need to start every morning with forgiveness).

  • It is not a restoration of full trust (trust takes time to develop or to be reinstated).

So what is forgiveness?

The Definition of Forgiveness:

Forgiveness is a process. It involves allowing yourself to feel the negative emotions you justly have towards an offense, and really putting the wrong into words in a congruent and authentic truthful way. Then choosing to release it, either giving it to a higher power, or letting it go to a cosmic sense of justice, or earthly legal justice system, and then continuing the process until negative affect is replaced with peace, empathy and compassion. When someone forgives they no longer have a portion of their daily life consumed in negative feelings towards the person or situation.  

“People, on rationally determining that they have been unfairly treated, forgive when they willfully abandon resentment and related responses (to which they have a right) and endeavor to respond to the wrongdoer based on the moral principle of beneficence, which may include compassion, unconditional worth, generosity, and moral love (to which the wrongdoer, by nature of the harmful act or acts, has no right)”  (Enright, 2015).

Elliot (2010) cited Enright and Fitzgibbons (2000) and came up with two types of forgiveness:

Decisional forgiveness: the experience of granting forgiveness without eliminating the emotion, but in this, resentment may continue. It involves a cognitive model where therapist works with the client one time to make decision to forgive.

Emotional forgiveness: the patient must demonstrate changes in emotion and motivation toward their offender.

Studies show that:

Decisional forgiveness can reduce hostility, but it is only marginally effective in improving stress levels or emotional health (Elliot 2010 citing Baskin and Enright 2004, Worthington 2007). This means that emotional forgiveness is the goal of all forgiveness therapy.

What’s the most effective way to help our patients forgive?

Individual therapy that accomplishes Enright’s 4 phases over 20 encounters is “clearly most effective” way to actually accomplish forgiveness. (Elliot 2010 citing Lundahl 2008)

Why should we care about forgiveness?

Forgiveness isn’t a “nice thing to do,” it has real health ramifications that have been thoroughly studied, and it’s a fact that the act of forgiving can be a real change agent in therapy and long term health.

Here are the studies:

  • People who live with depression and a history of maltreatment have an upregulation of their inflammatory response compared to those with no history of maltreatment (Danese et al. 2007 as cited by Elliot 2010)

  • Unforgiveness is reflected in specific cortisol levels, adrenaline production, and cytokine balance (Elliot 2010 citing Worthington 2005)

  • Cause-effect relationship between pain and anger is similar to the anger-depression relationship. some studies show that just the anticipation of pain is associated with anger. (Okifuji 1999)

  • Chronic pain often arises from injury, or accident, thus anger is directed usually at the one responsible, or oneself. (Greenwood 2003)

  • General intensity of anger is important, but also specific targets of anger seem to be essential factors in understanding adaptation to chronic pain. Some research has shown that inward anger is more common in those with chronic pain vs. those individuals with different targets of anger. A study using the MPI (multidimensional pain inventory- a 60 item self reported inventory to assess different aspects of chronic pain) showed that 88 people endorsed anger at themselves and scored 0.38 on the anger inventory. Those that endorsed anger at other targets all scored below 0.30. Anger should be viewed as a multifactorial construct in chronic pain. (Okifuji 1999)

Specifically, in chronic low back pain, a preliminary study of 61 adult patients with chronic low back pain (31 recruited from pain and palliative clinic, and 30 recruited from community) showed patients with higher scores on forgiveness-related variables (‘current level of forgiveness’ as measured by Enright Forgiveness Inventory and ‘forgiveness self efficacy’ as measured by the Forgiveness Self-Efficacy Scale) reported lower levels of pain, anger, and psychological distress.

Patients who scored  (Carson 2005) analysis revealed that “state anger largely mediated associations between forgiveness variables and sensory pain, whereas the association between current forgiveness and affective pain was mostly independent of state anger.”

What is bitterness?

When someone continues to hold on to unforgiveness, they can become what we would call “bitter.” Bitter people are exactly like that word describes—so steeped in resentment that they become unpalatable.

Clues that someone may be bitter:

  • Do they continually replay past hurts over and over?

  • Do they hold onto the pain?

  • Do they try to avoid someone?  

  • Do they quickly get angry with someone?

  • Do they speak trashfully or verbally malign someone?

  • Do they find that their bitterness is more associated with the proximity of the person who wronged them than the magnitude of the event?

  • What percent of their emotional energy is spent on this topic?  

* Recurrent resentment affects all relationships and takes up room in one’s emotional life.

What does research say about bitterness?

  • Ten years or more after a divorce, ½ of women and ⅓ of men are still intensely angry at their former spouses, and anger becomes an ongoing, dominant presence in their children as well (Wallerstein).  

  • Forgiving people have been found to have a lower blood pressure at baseline. (Larsen 2012)

  • “Recalled experiences of betrayal that were less forgiven were associated with greater cardiovascular reactivity as indexed by greater diastolic blood pressure, mean arterial pressure, and rate-pressure product…higher trait forgiveness was negatively associated with lower resting blood pressure and better post-stress recovery.” (Lawler 2005 citing Lawler 2003)

  • Those who measured high in hostility, 20-25 years later, had higher rates of heart disease (Shekelle 1983, Barefoot 1983).

  • When discussing the narrative of injustice, those with an understanding of forgiveness showed less anger expressions (Tina Huang, “Cross Cultural and Real-Life Validation”).

How can someone forgive?

If the previous studies about the negative effects of not forgiving aren’t enough, let’s look at some of the positive effects of forgiving.

Personal health results of forgiving:

  • Changes anxiety into inner peace, reduces symptoms of depression, anger, and paranoia (Dr. R. C. Hunter, 1978).

  • Genuine acts of forgiveness lead to overall improvement in the person’s emotional maturity and increases the capacities for courage, nurturance of others, and love (Dr. Morton Kaufman “The courage to forgive” 1984).

  • Reduces fear. Impulses of anger and revenge subside and are replaced by more appropriate expressions of anger (Dr. Richard Fitzgibbons).

  • Hypertension may be reduced (Huang 1990).

  • Patients with fibromyalgia who were taught forgiveness education had a significant decrease in symptoms (Lee, 2014).

  • Incest survivors showed significant improvement after a 1 year forgiveness education process (Robert Enright, 1994, 1995).

  • A study that looked at 20 psychologically abused and divorced women, some who had remarried and some who had not. All participants scored above 41 on the Psychological Abuse Survey was considered indicative of a present and serious pattern of emotional abuse. Randomized between forgiveness therapy (FT: based on the Enright model) with an alternative treatment (AT: anger validation, assertiveness, interpersonal skill building). The study found that the FT group showed a greater improvement in forgiveness, self-esteem, state anxiety, trait anxiety, depression, environmental mastery, finding meaning, post-traumatic stress symptoms all determined by pre-and post surveys and questionnaires. The FT group had an effect size of 1.79 and represents a shift from below normal levels to normative levels. (Reed 2006)

Spiritual Connection

Some patients highly value their higher power. You can ask them to turn to their spiritual power and ask for the grace to have the willingness to forgive. They can give the spiritual power the opportunity to work in their lives in that way. Some have had powerful forgiveness experiences with their higher power.

Steps in the process of forgiveness:

How can we help our patients forgive those who have wronged them? Sometimes our patients have experienced things that can hurt to even hear about. Helping them move from trauma and anger into a place of forgiveness so they can live a healthy emotional life can be difficult to navigate. But, it is a worthy journey to pursue.

Here are the steps I walk through with my patients using a workbook sheets I have created. I have included a FREE DOWNLOADABLE PDF below that you can give to your patients to fill out. It walks them through the steps in detail, giving them a drawing to fill out and journaling exercises with specific questions to answer that will help them process their trauma and grief.


Further Reading on Forgiveness:

“Forgiveness is a Choice” Enright

Bradley, L. A., McKendree-Smith, N. L., Alberts, K. R., Alarcón, G. S., Mountz, J. M., & Deutsch, G. (2000). Use of neuroimaging to understand abnormal pain sensitivity in fibromyalgia. Current Rheumatology Reports, 2, 141–148.  

Brand BL, Alexander PC. “Coping with incest: the relationship between recollections of childhood coping and adult functioning in female survivors of incest.” J Trauma Stress. (2003):185–93.

Enright, R. D. Forgiveness is a choice. (2001) Washington, DC: American Psychological Association.

Fernandez, Ephrem, and Dennis C. Turk. "The Scope and Significance of Anger in the Experience of Chronic Pain." Pain (1995) 61(2):165-75.

Greenwood K, Thurston R, Rumble R, Waters S, Keefe F. Anger and persistent pain: Current status and future directions. Pain. (2003);103:1–5.

Knight JR, Hugenberger GP. On Forgiveness. Southern Medical Journal. (2007). 100(4):420-421.

Larsen BA, Darby RS, Harris CR, Nelkin DK, Milam PE, Christenfeld NJ. The immediate and delayed cardiovascular benefits of forgiving. Psychosom Med. (2012) Sep;74(7):745-50.

Lawler, K. A., Jarred W. Y., Rachel L. Piferi, Rebecca L. Jobe, Kimberley A. E, and Warren H. J. The Unique Effects of Forgiveness on Health: An Exploration of Pathways. J Behav Med Journal of Behavioral Medicine (2005). 28(2): 157-67. Web.

Lee YR, Enright RD. “A Forgiveness Intervention for Women With Fibromyalgia Who Were Abused in Childhood: A Pilot Study.” Sprituality in Clinical Practice. (2014). 1(3):203–217

Lichtenfeld S, Buechner VL, Maier MA, Fernandez-Capo M. Forgive and Forget: Differences between Decisional and Emotional Forgiveness.PLoS One. (2015) May 6;10(5):e0125561.

Moons, Wesley G., Naomi I. Eisenberger, and Shelley E. Taylor. "Anger and Fear Responses to Stress Have Different Biological Profiles." Brain, Behavior, and Immunity (2010) 24(2):215-19.

Muscatello MR, Bruno A, Scimeca G, Pandolfo G, Zoccali RA. “Role of negative affects in pathophysiology and clinical expression of irritable bowel syndrome.” World J Gastroenterol.2014;20:7570–7586.

Okifuji A, Turk DC, Curran SL. Anger in chronic pain: investigations of anger targets and intensity. J Psychosom Res. 1999;47(1):1–12.

Reed GL, Enright RD. The Effects of Forgiveness Therapy on Depression, Anxiety, and Posttraumatic Stress for Women After Spousal Emotional Abuse. Journal of Consulting and Clinical Psychology. (2006). 74(5):920 –929.

Schmidt S, Grossman P, Schwarzer B, Jena S, Naumann J, Walach H. “Treating fibromyalgia with mindfulness-based stress reduction: results from a 3-armed randomized controlled trial.” Pain. (2011).152(2):361–9.

Strang S., Utikal V., Fischbacher U., Weber B., Falk A. “Neural correlates of receiving an apology and active forgiveness: an fMRI study.” PLoS ONE. 9:e87654 (2014). 10.137.

White, JM. “Pleasure Into Pain: The consequences of long-term opioid use.” Addictive Behaviors. (2004). 29:(1311-1324).

Winfield JB. Psychological determinants of fibromyalgia and related syndromes. Curr Rev Pain. 2000. 4(4):276-86.

Witvliet CVO, Phipps KA, Feldman ME. Beckham JC. “Posttraumatic mental and physical health correlates of forgiveness and religious coping in military veterans.” J. Trauma Stress. (2004) 17:269–273.





What is Transference and Countertransference?

On this week’s episode of the podcast, I talk about transference and countertransference. It’s the fourth episode in my four-part therapeutic alliance series where I discuss best practices on dealing with the doctor - patient relationship.

Here are the three previous episodes:

Part 1 - Introduction

Part 2 - Logotherapy and Meaning

Part 3 - What is empathy and how to improve it

What is transference?

Historically the term “transference” refers to the feelings, fantasies, beliefs, assumptions and experiences unconsciously displaced on the therapist that originate in the patients’ past relationships. More recently, transference is seen as the here and now, valid experience the patient has of the therapist.

It is “a mixture of real characteristics of the therapist and aspects of the patient’s figures from the past—in effect, it’s a combination of old and new relationships.” (Gabbard)

How does transference work?

The patient’s early experiences develop organizing principles, constructing a framework for future interpersonal interactions. (Maybe their dad was an abuser, so they project that you will abuse them.) Transference is the continuing influence of these ways of organizing and giving meaning to experiences. They crystallized in the past, but they continue in an ongoing way in the here and now. The therapist’s actual behavior is always influencing the patient’s experience of the therapist because of this.

When a patient visits a therapist, they seek a new developmentally needed experience, but they expect the old, repetitive experience.

There is often misattunement to painful circumstances that can't be integrated into a person’s emotional world. For example—a child who can’t demonstrate his emotion in a way that his parents can handle causes the parents to move away from the child, creating distance. The child then subdues the emotion and creates a new “ideal self” so they can interact with others and no be rejected. The child then doesn’t know how to deal with strong emotion, even moving into adulthood.

Unintegrated affects become lifelong emotional conflicts and vulnerabilities to traumatic states.  To handle the difficult situation, they develop defense mechanisms. Those defenses against affects become necessary to maintain psychological organization.

That “ideal self” will stay in place with others until you come along. If they see you as a safe person, they will express their emotions—anger and all—towards you.  


This is where it’s important to understand transference, and to be able to give your patient a safe place to express their emotions.

When we understand transference is happening, we can listen from the patient's world, acknowledge their subjective perspective, resonate with them, look for their meanings, and form and alliance with the patient's expressed experience.

Of course we must expect their hesitations to trust us, avoid us, have feelings of shame, guilt, and embarrassment...it is uncomfortable to share what one feels.

Positive Transference

Negative transference isn’t the only type of transference—there is also positive transference, where you remind the patient of a positive relationship they had, so they feel deeply connected to you. People with borderline personality disorder are very quick to attach, usually commenting that they have never felt so close to a therapist before. When someone does say very positive things to me, especially in the first few sessions, I let them know that it’s also okay to express negative feelings towards me as well.  

Transference-focused therapy

Kernberg wrote about transference focused psychotherapy. He hypothesized about the developmental birth of borderline personality disorder. By exploring and integrating these “split-off” cognitive-affective units of self and other representations, patients will be able to think more coherently and reflectively. They will be more realistic and accurate in their thoughts, feelings, intentions and desires about themselves and others. Integration will allow for increased modulation of affect, coherence of identity, increased capacity for intimacy, and improved functioning (Kernberg 2008).

Levy (2006) studied transference focused psychotherapy (TFP) vs dialectical behavior therapy (DBT) vs supportive psychodynamic psychotherapy for borderline personality disorder. He found that TFP had increased secure attachments (whereas the other 2 did not change it), with increased narrative coherence. It also improved reflective function—the ability to mentalize the thoughts, feelings, goals of another person.

What are some common transferences?

  • Sibling rivalry

    • Competitiveness, comparing, jealousy.

  • Maternal

    • Possibly see you as nurturing or abusive.

  • Paternal

    • Possibly wants you to solve their problems, asks for direct advice.

  • God

    • Where they want you to be all powerful or omnipotent.

  • Erotic

    • One of their primary attachment figures might have sexualized them, so they might yearn for erotic attention and affection. Perhaps a patient falls in love with you, or someone similar physically to you.

  • Idealizing or contemptuous

    • They could view you as a savior, or feel contemptuous to you.

  • Passively hoping for a miracle

  • A person prone not to trust will view the therapist with suspicion

  • A person who struggles with anger will have anger towards the therapist

  • Transferences are influenced by age, gender, clothing, bodily attributes, context, vocabulary & choice of words, personality characteristics

  • Be a certain way to have you stay connected with them  

How do deal with transference in therapy:

Here is the main, overarching principle when dealing with transference: have empathy. Be empathic. Be open to their feedback. Don’t take things personally. Be connected with your patient. Developing a therapeutic alliance requires you being connected, and being connected requires you to allow your patient to explore their emotional world with you. That requires psychological safety.

When you are a safe place, they will hopefully be able to connect, and you can help them identify their transferences so they have a chance at developing healthy relationships in the future without bringing their past with them.

If my patient had a previous therapist, I always ask them, “What went well and what did not go well in your past therapy relationship?”

Other questions I ask are:

  • “How would you like your past therapy to have been different?”

  • “When you felt disappointed and misunderstood, were you able to share that feeling with your therapist?”

  • “In what ways would you like your relationship with me to be like your experience with your last therapist?”

  • “What are some of your worries about what you might experience in your treatment with me?”  

When I can tell they don’t want to come to therapy. I normalize their feelings so they feel like they can share with me.

  • “This is a laboratory where we look at what goes on between us, and when you tell me you are mad at me, I am going to be excited about your sharing your feelings, good or bad.”

  • “What are you feeling about leaving me for the day?”

  • “What did you do when you were young and something bad happened to you?”

    • “Go to mom? Go to Dad? Go out alone?”

    • “When you looked for help how were you responded to?”

    • “Were you comforted? Did it help?”

    • “How did it make you feel when you wanted somebody to help your upsetness?”

    • “I want to be with you in this moment of sadness and loss.”

When you sense an empathic strain, mending it is priority number 1. I might say, “Help me understand what I might not have understood here.” Or, “If I said something that makes you feel worse about yourself then let’s talk about it now.” Try to prevent an empathic strain from progressing to an empathic rupture in your relationship by catching the strains early on.

Here are a few tips to handle when patients exhibit strong emotions towards you:

  • Be enthusiastic and curious about patients’ experiences when coping with intense feelings.

  • Be particularly encouraging about them discussing their feelings, and especially their feelings towards you. Whereas in the past there might not have been a  safe place to get angry, they are entitled to want to have a different experience with you.

  • Say explicitly that they are allowed to have all of their feelings (including loving and hating) in the therapy relationship and that they will be dealt with in words and not in actions.

  • Convey to them that they can feel secure and accepted and not reproached or rejected, even if they have negative feedback or feelings towards you.

  • You can work cooperatively to help them process and modulate their emotions.

  • You can explore together what actions might be appropriate for them when the flooding feelings erupt and they are unsure about what might happen as consequences.

  • Complicated emotions are inevitable: the opportunity we offer is to enhance ways of coping with desirable as well as disruptive emotions. Emotions may be congruent with experiences in the past, but not necessarily appropriate in the present context in which they recur.

When we are young, we are unable to metabolize emotions correctly, especially in the face of trauma or an unsafe caregiver. When we age, we transfer those patterns of belief onto every other relationship in our life, trying to recreate that. When you, as a therapist, offer a safe environment for a patient to experience those strong emotions, you are helping them rewire their belief system around those emotions. It allows them to interact with every other person in a new way.

Countertransference:

The original and narrower definition of countertransference centered around the therapist unconsciously experiencing the patient as someone from their past (similar to transference). Now, countertransference is seen as the therapists’ total reaction to the patient.

First, it’s important to note that therapists need to practice what they preach: do the work in your own therapy so you can identify your own transferences. The less clouded your vision is of what’s happening in sessions, the better. For example, one therapist saw nearly every patient as a trauma victim, and occasionally led them to believe they’d been traumatized as well in the same way.  

Countertransference is seen as a source of important information about the patient: it can be a major diagnostic and therapeutic tool. “Countertransference is an instrument of research into the patient’s unconscious.” (Paula Heimann)

Now it is seen as a jointly created reaction in the clinician (some reactions from the therapist's past, some induced by the client's behavior).

There are continuously fluctuating levels of influencing the transference and countertransference by contributions from both patient and therapist during all their interactions. My mentor, Dr. Tarr, said, "To every relationship we bring learned expectations from past encounters.”

One way to handle countertransference to make sure you are coming from a healthy place is to use your left brain to integrate with, and therefore dampen, the right brain. Learn from what you are feeling during the session, but observe yourself with curiosity.

Another form of possible transference is sexual attraction towards a patient. Studies show that 85% of male therapists at some point have erotic arousal towards a female patients. Obviously, it is important to not act on or tell your patient about those feelings.

You should also allow yourself to mirror the patient’s emotions, as to follow the patient’s emotional movements and unconscious content.  

Before a patient enters the room, check in with yourself. How are you feeling? What are you feeling?

Here is a checklist I like to use before my sessions with patients. It is based on 7 basic emotions:

  •  Disgust

    • I dislike him/her.  

    • I feel repulsed by him/her.

  • Attraction

    • I have compassion for the patient.

    • If they were not my patient I would want to date him/her.

    • I feel sexually attracted to him/her.

    • If he/she were not my patient I would want to be their friend.

    • I look forward to sessions with him/her.  

    • I wish I could give him/her what others never could, protect him/her like no one could...

    • I feel I understand him/her.  

    • I have warm, almost parental feelings towards him/her.

    • I self-disclose more about my personal life with him/her more than with other patients.

  • Sadness

    • I wish I had never taken the patient on...

    • I feel sadness/depression in sessions with him/her.

    • I feel guilty about my feelings towards him/her.

    • I feel guilty when she/he is distressed or deteriorates, as if I must be somehow responsible.  

  • Angry

    • I feel dismissed or devalued.

    • I feel annoyed in sessions with him/her.

    • I feel criticized in sessions with him/her.

    • I feel angry with him/her.

    • I feel anger at people in his/her life.

    • I feel competitive with him/her.

    • I feel used or manipulated by him/her.

    • I have to stop myself from being aggressive or critical with him/her.

    • I feel pushed to set firm limits with him/her.

    • I feel resentful working with him/her.

  • Dissociation/Shut Down

    • I feel confused in sessions.  

    • I am overwhelmed by strong emotions with him/her.

    • I feel hopeless working with him/her.

    • I feel like my hands are being tied or that I have been put in an impossible bind.

  • Sensorium issue

    • I feel bored in sessions with him/her.

    • My mind wanders to things other than what he/she is talking about.

    • I feel sleepy when talking with him/her.  

  • Fear/Anxiety

    • I feel anxious/frightened working with him/her.

    • I fear I am failing to help him/her.

    • His/her sexual feelings towards me make me anxious or uncomfortable.

    • I fear being incompetent or inadequate to help him/her

    • After treatment ends I worry about him/her more then most patients.

It is completely normal to have feelings—both good and bad—towards patients. We are humans, not robots! Sometimes it might seem like you’re supposed to be perfect or void of feelings towards your patient, but that doesn’t allow a living, growing, healthy therapeutic alliance towards them. The important thing is to notice how you feel, without self judgement. Then, deal with those feelings in a healthy manner, like through seeking out your own therapy, getting a mentor, etc. However, sometimes merely allowing yourself to notice the feelings and owning up to the feeling of anger, attraction, boredom, or sadness, is enough to dissipate it.

It’s easy to be busy after a session. It’s better to practice noting your feelings. After all, how can we help our patients express and normalize their feelings if we cannot do it for ourselves?

Conclusion

If you are a mental health professional, I would love for this to be your community. We are in these trenches together, and it’s pretty common for therapists to feel totally exhausted and burned out from all of the countertransference. I hope that through this community, we can develop better practices, help each other, and grow together.

If any of you have any questions or listen to the podcast, I’m active on social media. I’d welcome any feedback you have. My social handles are: Instagram @Dr.DavidPuder, Facebook: @DrDavidPuder, or Twitter @DavidPuder




Reducing Inpatient Violence in a Psychiatric Hospital

Reducing Inpatient Violence in a Psychiatric Hospital

Violent aggression in the inpatient psychiatric setting has developed into an important issue that negatively affects patients and staff. There are some simple and surprising treatments different clinics are taking to prevent violent aggression. It’s time we paid attention to this issue so we can prevent injury of both patients and hospital staff.

Depression and Anxiety in Geriatric Patients

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On this week’s episode of the podcast, I am joined by Dr. Carolina Osorio, a geriatric psychiatrist (and one of my favorite people). After she finished her psychiatry residency, she also went on to finish a fellowship in geriatric psychiatry to take care of her favorite people. Dr. Osorio runs a special program that treats elderly people with depression and anxiety.


Mental health in the elderly

Sylvia Yu (MS3), David Puder, M.D.

As many people age, their health declines, and their needs increase. At the same time, we can experience loss of spouses because of aging, loss of friends and fear of death. We can lose eyesight, hearing, and subsequently, our drivers licenses and autonomy. It can be an incredibly stressful and lonely time.

At this time in history, like no other time before, we are experiencing a wave of baby boomers that will put a new strain on our already waning mental health facilities. Baby boomers are also more likely to stigmatize using mental health services.

Dr. Osario noticed these problems and she took steps to create a program that is helping her local aging population in a way that makes them feel comfortable.

If you are a primary care physician, psychiatrist, or a family member that is a caretaker for the elderly, this article will have takeaways from Dr. Osorio’s program that can help clarify how we can best help the aging population.  

When Dr. Osorio was a resident, she noticed that in mixed-age groups, older adults didn’t get the treatment that they needed. A general outpatient partial program wasn’t benefiting them, and sometimes it would make them worse because older adults tend to become parents to their younger peers in their group. She noticed that the older adults ended up taking care of their younger counterparts and not getting the individualized help they needed.

She started building a program to help the elderly in the way that they needed to be helped—through diet, exercise, therapy, medication management and stress reduction.

Medically, older adults have comorbidities, or more than one medical issue that needs to be treated. Because of this, having a geriatric therapist, group therapy session, or a geriatric mental health program can keep them happier, healthier and independent for longer.

If you run an outpatient group for the elderly, if you’re suggesting one for your patient, or if you are looking for one for an elderly friend or relative, here are a few things to consider:

  • Small groups - It takes longer to express their stories, to receive feedback, and to cognitively process information. Because of this, there should be no more than 8 participants in any one session.

  • Medication support/management/consultation - Often, elderly people are on too many medications, and this could be slowing them down physically, causing mental decline, and speeding up the aging process. We will make suggestions below on how medications can be managed.

  • Evidence-based therapies - A good outpatient elderly care program will also include evidence-based therapies (Bartels, 2003) to help the patients cope with their depression and anxiety, such as cognitive behavioral therapy (CBT), problem solving (Malhouff, 2007), reminiscence therapy (Elias, 2015), nutrition education, and medication education. Below, we will go into these therapies and why they are helpful.

Medications for aging adults

Benzodiazepines

Unfortunately, many elderly patients are prescribed benzodiazepines—drugs used to treat anxiety. Many primary care doctors have busy schedules with short appointment times. When the patient has hypertension, diabetes and osteoporosis, mental health can take a back seat to managing the more urgent health issues. The primary care doctor will usually just prescribe a benzodiazepine to deal with the anxiety issues.

There are several problems with giving benzodiazepines to the elderly. With time, the body gets used to the benzodiazepine, and the doctor starts to increase the dose. Then, the patient typically becomes even more depressed, more lethargic. This, in turn, increases other health issues.

That is why special consideration should be given when prescribing “benzos” to the elderly. It is also why Dr. Osorio’s goal in her outpatient program is to taper them off of their benzodiazepine medications. She says many of the patients she sees have been on them for 20-30 years.

Tapering a patient off of a benzo should be done very, very slowly in order to avoid delirium or worsening of anxiety.  

For example, if the patient is on 4mg of Xanax a day, Dr. Osario will convert them to Klonopin. Because of the half-life of the medication, the patient will have fewer symptoms of withdrawal when they start coming off of it. Then, she would reduce the dosage to 3mg of Klonopin over the next six months to a year.

Anticholinergic medications

As we age, our brain changes and there are parts of the brain that are going to have synapses that decrease. Acetylcholine actually decreases with age. But, if you add a medication that is anticholinergic, you are putting a bigger burden into that normal process. Then, there can be bad side effects such as confusion and dementia.

Because of that, Dr. Osorio says she will typically taper off or replace any medication with an anticholinergic burden. For example, the antidepressant Paroxetine is a no-go drug in the elderly population because it is very anticholinergic. The tricyclic antidepressants are also very anticholinergic. Nortriptyline, however, is one that Dr. Osorio would prescribe because it has much less of the anticholinergic burden at lower doses.

(I will put a list up on my website in my resource library of the different medications that are anticholinergic. Along with “Beers list,” medications that are contraindicated in older adults.)

Lithium

Physicians don't often think about lithium. Lithium is brain-protective (Forlenza, 2014). It has many functions that are very healthy and it actually produces neurogenesis in some patients. Consider, if you have a patient on an SSRI that isn’t responding how you’d like, adding a tiny dose of lithium (usually about 150-300mg).


Medication management for the elderly

Psychiatrists must work very closely with the patient’s primary care doctors. There are primary care doctors who also have a fellowship in geriatrics, but most do not have the specialized training needed to maximize mental health and minimize side effects. Sometimes it is helpful to have a conversation on behalf of the patient and guide them in certain medications. Every doctor should think about the whole body in general, and working with a primary care doctor can help psychiatrists do that.

A lot of older adults start feeling better when you start decreasing their meds. This indicates they were just depressed and did not have Major Depressive Disorder that required a heavy load of medications to manage it. It also shows that the depression was a side effect of medications. That, really, is the first thing you want to think about when you have a new patient and you see a very large list of medications that they are taking—are the symptoms because of the medication or is the medication helping alleviate symptoms? Should they be taking every single medication on the list?

There are a couple of studies that have talked about serotonin in older, depressed patients and how that can delay the progression of mild cognitive impairment of Alzheimer’s (Smith, 2017). One study showed that SSRIs are the best medications for it—Wellbutrin, SNRIs, tricyclics. There is actually another study done with older adults who had mild cognitive impairment and a history of depression (Bartels, 2018). Those who were taking SSRIs delayed progression of mild cognitive impairment by three years. But, in those patients who were put on another type of antidepressant, the progression was faster.

However, it is important to note that putting an elderly patient on an SSRI does not deal with the root of the issue. Therapy in conjunction with medication has been shown to be more powerful and sometimes eliminate the need for medication. If the patient is lonely, eating poorly, and has no life activities to look forward to, changing those factors can decrease the need for medication. Always consider therapy in addition to any psychiatric medication.

No matter what you prescribe, the patients have to take the medication for it to be helpful. Make sure to write down the medication, dosage, and times in clear language. Help the elderly patient understand what to take and when. When necessary, get helpful family members involved to remind the patient as well.

Therapy for the elderly

Another component of aging healthfully is receiving therapy. The cognitive load of aging alone, including the sum total of traumatic experiences, is often enough to require therapy to help with life transitions.

There are many forms of therapy available that can help the elderly experience a fuller life, deal with trauma safely, manage their depression and anxiety, and even stay mentally sharper for longer.


Problem solving therapy for the elderly

Problem-solving therapy is a way of teaching the elderly how to find ways to solve the particular problems that are unique to them. These problems cause anxiety and depression, so teaching them how to think about them, how to solve problems themselves, can give them a sense of autonomy and control. Sometimes, in therapy, you cannot solve the actual problem, per se, but the process of working through it together gives them different options that they can utilize if their anxiety starts to spike when they are alone.

For example, one elderly lady Dr. Osorio works with struggles with terrible anxiety. She recently broke her arm. She couldn’t clean her home, and her family would come over to help. She felt like a burden to them and was very anxious about this. During problem solving therapy, they  made a list of all of the things that needed to be done around the house, and then they marked the three things she could do, even with her broken arm, to help. She felt better knowing she could help her family while they were helping her. Even though we couldn’t fix the problem, we made it manageable, and gave her some autonomy back.


Reminiscence therapy for the elderly

In reminiscence therapy, you focus on reminiscing about good things. For example, Dr. Osorio will bring her elderly patients a picture of a turkey. She will ask them what it reminds them of. Everyone starts talking about Thanksgiving with their families. They discuss memories, smells, and they walk through the senses of what it was like for them at a happy time. This alone starts to fire up positive emotions in their brains and can change their moods instantly.

The cool thing about reminiscence therapy is that it even works with patients who have dementia, because their long-term memory is pretty solid. They can dip into their past and they immediately start brightening up. Their whole countenance changes.

It is a simple therapy to use, and it can be very helpful when dealing with depressed patients. They often feel alone, but when they begin to talk about the good times and share memories, it connects them to others in their group, and helps them make positive social connections.

Cognitive behavioral therapy for the elderly

There are also behavioral activations we can implement to help the elderly. The elderly patient typically has a hard time with scheduling routines. As their therapist, it can be helpful to get them to schedule a solid routine they can stick with because we have to break the cycle of depression and anxiety. For example, if you're depressed, you want to be in bed, you stay in bed, you get more depressed. This is damaging to an elderly person because it is much harder to get them to start scheduling and moving around again once they slow down. Activating their schedule can be a first step in keeping them independent for longer.

For elderly cognitive behavioral therapy, first, we do education on this process and then start helping them find ways in which they can break that lethargic routine. We want to help them choose an activity that they want to do so that it’s easier to break that cycle. Maybe that is going every Sunday to visit their grandkids. Maybe they can join a card game club, join a church, a quilting group, a storytelling group or take a community educational class. That one simple thing can break their cycle of depression, ease loneliness, and keep them engaged for longer.  

Aging and brain health

The evidence for maintaining brain health while aging says there are several things we can do to stay healthy: physical activity, socialization, nutrition and stress management.

Physical exercise

Dr. Osorio’s favorite exercise to recommend for the elderly is tai chi. Tai chi decreases the risks of falls in older adults (Lomas-Vega, 2017). There are even insurances that are starting to pay for tai chi for older adults because it is cheaper than fixing a broken hip. It’s a very easy, very smooth exercise.

For the wheelchair-bound, she recommends chair exercises. A physical therapist can help the patient move their arms, their torso, their necks. Maybe some of them can lift their legs from the knee up. Even if they can’t, they can still get a good exercise in and get some positive movement going.

When the elderly patient is doing really well in exercise they can start to add weights. Weights are very important because when they use weights their muscles are contracting and they’re positively impacting those bones. This is a good way to decrease osteoporosis. Even with the elderly, muscles can get stronger and their strength can increase. Studies even show that exercise in the elderly pretty much halts the dementia progression.


Socialization

Socialization is also very important. One study showed that the higher risk factor for morbidity and mortality was related to isolation (Holt-Lunstad, 2015). Isolation is actually toxic for our brains. If someone is home alone, they will usually die faster.

Being with friends and family and maintaining a social life helps the brain because it uses visuospatial skills, social skills and cognition. A simple conversation, a regular visit with a loved one or a new person can help an elderly person maintain positive brain health.

Human connection is necessary throughout all of life, and to have close, connected friends makes a huge difference. As part of her program, Dr. Osorio notices if they're having issues making friends, and she helps them create some behavioral activation to get them to places where there is a potential of making friends.


Nutrition

As far as nutrition goes, we have to take into account that the elderly population is pretty diverse. There are 60 year olds who are very fragile because of many health problems and there are 90 year olds who are pretty healthy.

Dr. Osorio personally recommends the Mediterranean diet. The Mediterranean diet is a diet that consists of grains, fish, olive oil, avocado, fruits and vegetables. The Mediterranean diet offers omega-3 fatty acids in the fish, high poly and monounsaturated fats in the olive oil and in the nuts.  There is also a lower amount of sugar then the average American diet. If elderly patients are struggling with making the big change in their diets, it’s best to merely suggest they don’t consume processed foods.

The Mediterranean diet has been associated with a reduced risk of developing mild cognitive impairment (MCI) or progressing to Alzheimer disease from MCI (Scarmeas, 2009). This year it was the number one diet recommended by the medical field.


Stress management

Stress reduction also adds to positive brain health. Mindfulness and visualization are both helpful practices to reduce stress. Stress reduction is not a one-time fix all. It is something that has to be practiced every single day in order to work.

Ask the patient to download a meditation app if they are technologically savvy, or even join a meditation group for seniors to increase their socialization. If neither of those works, getting them to quietly rest and close their eyes for even five minutes with the intention of relaxing, not just to nap or sleep, can have positive benefits.

Conclusion

If you work with the elderly, or know someone who is elderly, if they struggle with mental health issues such as anxiety and depression, or have comorbidity with other health issues, consider suggesting an outpatient group therapy for the elderly. It can be extremely helpful when paired with nutrition, exercise, and a cohesive plan with their primary care physician.

Other episodes I HIGHLY recommend if you are interested in treating elderly people:

Sensorium: Total Brain Function Optimization Part 1

Psychiatric Approach to Delirium with Dr. Timothy Lee

Questions, comments, thoughts? Please comment on the picture that corresponds to this post on my instagram: @Dr.DavidPuder

The Dark Triad (Psychopathy, Narcissism, Machiavellianism), sexually violent predators, Ted Bundy, and porn.

On this week’s episode of the podcast, I interview...quite a few people! We are covering Ted Bundy, America’s most infamous serial killer, and since the world has been fascinated by him lately, I figured I’d get a group of mental health professionals in a room to talk about him. His horrific acts made the news and have scared people for decades now, and rightfully so. Did media and pornography cause this? What was his diagnosis and was it correct? We have so many questions...


As my special guests and panel of experts, I invited Dr. Tony Angelo, who is head of services for a local prison and in charge of prisoners transitioning into normal life. I also invited Dr. Randy Stinnett, a clinical psychologist who co-manages an outpatient behavioral health department in a local community health clinic. Also with me is Nathan Hoyt and Adam Borecky, 4th year medical students who will be going into psychiatry.


Traits of psychopathic antisocial behavior


Criminals like Ted Bundy are skilled manipulators. They often scope their environment to see who will be the easiest to manipulate. They will treat you like you are their long, lost friend, but everything they do is an attempt to pull you in. They “hook” you so that they can get you to do something for them.

Ted Bundy came off as friendly and charming, described as “one of us.”  A friend of his from Washington State even said, “He’s the kind of person you’d want your sister to marry.” As disturbing as this is, it is a common trait of psychopathic antisocial behavior.

Ted Bundy displayed many traits of psychopathic antisocial behavior. Some of the most recognizable traits were:

  • Viewing others as a pawn in his chess game

  • Master manipulator

  • Desire control/power

  • Sexual gratification in his choices

  • Enjoyed having an audience

  • Calculated predatory aggression

  • Strategic planning

  • Feeling that some other entity is operating inside of him

Empathy qualities:

  • Normal cognitive empathy

  • Very low affective empathy


Someone with low affective empathy will not feel your emotions or know your emotions from a mirror neuron experience. Rather he can only read facial expressions and body language without allowing cognitive but not affective empathy.  


In episode 2 of the Ted Bundy documentary on Netflix, Confessions with a Serial Killer, in his first arrest Ted Bundy said, “A funny thing happened to me on the way to labor law class. I got two weeks on the spa on the labor floor here. And, a yes, I intend to complete my legal education to become a lawyer, and be a damn good lawyer. Uh, I think things are going to work out, thats about all I can say.”


When he said this, he had a right sided smile and outwardly looked fairly happy and calm. According to studies done about microexpressions, the right sided smile is usually demonstrating contempt, but for him does not look as negative, and because in so many of his videos he has it on his face, he likely thought highly of himself and looked down on others.

I have noted that very good liars look positive, but often still leak microexpressions of very subtle negative emotion. Bundy seems to have expressed anger when he felt thwarted. In his statement, he makes a joke, yet showed a flash of fear or sadness while doing so. Bundy’s emotions of fear, anger, sadness, and pain leaked out through the microexpressions on his face, which are always a truth-telling mechanism.

Below is the quote with my inserted microexpressions in it:

“[contempt] A funny [anger] thing happened to me on the way to labor law class. I got two weeks on the spa on the labor floor here [fear or sadness]. And, a yes [contempt, sadness or fear], I intend to complete my legal education to become a lawyer, and [contempt] be a damn good lawyer [anger]. Uh [pain], I think things are going to work out [fear], thats about all I can say.”

*Note it is hard to determine exact expressions from the poor quality of this video- but my microexpression research team discussed the above and this was our consensus.  The fear or sadness comment comes from the eyebrows going up in the middle, but it is hard to determine if there is fear or sadness due to the poor quality of film.


It is believed psychopaths feel little or no fear. Did Ted Bundy feel afraid?

Most of the video of Ted Bundy did not show a physiological reaction to stress. But it is likely to some degree (although much less than others) that he experienced fear.  It is thought that those with primary psychopathy have dysfunctional emotional processing due to issues in their amygdala. Studies show they have less fear then control groups and secondary psychopaths (more the sociopath or baked ones) which have more trait anxiety or fear (Skeem, 2007).    

What was Ted Bundy’s possible diagnosis?

Primary psychopathy: These typically have low affective empathy and low fear, however not all that are primary psychopaths become criminals. They are sometimes able to still follow the rules while not having any fear or empathy and can even be prosocial.

Sociopath (or secondary psychopathy): These are typically “baked” into being anti-social. Sociopaths are typically “made” to be the way they are, often resulting from a traumatic childhood. Abuse and trauma may influence their later life ability to attach to others.  They have higher trait fear, more borderline traits and more mental disorders.

Antisocial Personality Disorder:  This is how the DSM classifies people who have a history of illegal behaviors, deceit, impulsivity, failure to plan ahead, aggressiveness, reckless disregard for safety, irresponsibility and lack of remorse.  This is usually a criminal psychopath or sociopath with repetitive crimes. They display low empathy and low connection with others. Their behavior usually results in crimes against others.  

Ted Bundy’s bipolar diagnosis:

When Ted Bundy was assessed while awaiting his death sentence, he was given a diagnosis of bipolar disorder. However, most depressed people become less violent and don’t have much of a desire to have sex. It is also interesting to note that out of all of the violent events that happen in the US, only 5% of them are due to mental illness (Stuart, 2003). Therefore, we can conclude that most violent acts are not done by people with mental illness.

Could he have been in a manic state?

Most manic states end in death, jail or psychiatric hospitalization. Ted Bundy had no record of being hospitalized in a psychiatric hospital and was only put in jail after he was caught. Bundy was also capable of living a “normal” life. He was an active citizen, joined a church, was married and involved in politics. He played these roles for years.


With mania, this would not have been possible. Those who are manic cannot stop their mania. Also, Ted Bundy displayed reason in the midst of his crimes. He covered his tracks and could pretend to be something he wasn’t. Those who are manic do not have the ability to pretend to be something they are not, nor have the ability to plan and cover up.

DSM 5 antisocial disorder:

Ted Bundy would fall more in line with a DSM 5 antisocial disorder leaning more towards primary psychopathy. With this disorder, you must be 18 years or older and have commited conduct disorder before age 15. Also prevalent is a pervasive pattern of disregard for the rights of others since the age of 15 and psychopathic manifestations. Additionally, they must meet 3 or more of the following behaviors:

  • Fail to conform to lawful behaviors

  • Deceitfulness

  • Impulsivity

  • Irritability

  • Aggressiveness

  • Reckless disregard for the safety of others

  • Irresponsibility

  • Lack of remorse

Nearly all of these traits were displayed in Ted Bundy’s pattern of behavior. Even when he was young he showed predatory aggression (which I discuss in a prior episode) when he set up tiger traps at camp and injured a young girl. Although he prayed with people before his death, Ted Bundy’s memorable quote, “I am in the enviable position of not having to feel any guilt,” showed he was wired with some primary psychopathy.

Low IQ

Although Ted Bundy has been referred to as a criminal “mastermind,” he may have had a average or only slightly above average IQ. The article by Ceci, 1996, found that cognitive ability tends to be a good predictor of academic performance; measures of academic achievement (LSAT, GRE, SAT) correlate very highly with measures of cognitive ability.

Although we do not know Bundy’s actual LSAT score, only that he believed it was “mediocre,” there is certainly no evidence that states he was a genius.  Rather than a genius, I would say he was not impulsive, very calculated, and often planned and put a lot of energy into his criminal actions.

Hearing voices

Ted Bundy often referenced hearing voices that told him to do bad things. However, it is not believed he had schizophrenia. Occasionally antisocials will use this as a way to avoid responsibility for their behaviors.

We call it MBD: minimize, blame and deny

Was pornography to blame?

Ted Bundy blamed his behaviors on pornography. However, pornography is not viewed as a cause of sexual violence. In persons who have preexisting conditions for sexual violence, it is a viewed as a contributing factor.

In Episode 4 of the documentary, he is quoted as saying, “I never said (pornography) made me do it. I said that to get them to help me. I did (murder) because I wanted to do it.”

The research confluence theory states men with hyper masculinity that also involves psychopathic tendencies have low agreeableness, abuse, hostility towards women, impersonal sexuality combined with sexual permissiveness. When you have a confluence of those two things and violent pornography it may be a contributing factor to Ted Bundy’s violent, abhorrent behavior.

It is important to note that pornography has not been present in our society for very long. Yet, crimes against women have been happening since the beginning of time. It is because of this fact that many doubt that pornography is to blame for crimes of this nature.

Hald, 2010,  found that the correlation between violent pornography and attitudes supporting violence against women (r=0.24) was significantly higher (P< 0.001) than the correlation between nonviolent pornography and attitudes supporting violence against women (r=0.13): however these are still low correlations.  

Antisocial personality disorder and psychopathy as a mental illness:  

Just because antisocial personality disorder is in the DSM, it doesn’t mean it should be viewed the same way we view schizophrenia, bipolar, major depressive disorder, etc. Largely, antisocial personality disorder is not something that is treated by psychiatrists. There is no medication for it and most with this disorder are not interested in help. If they come to see a psychiatrist, it is typically because they want something from you.

Narcissism diagnosis:

Ted Bundy had traits of narcissism as displayed in the DSM 5 criteria: a pervasive pattern of grandiosity, lack of empathy and a need for admiration which begins by early adulthood. To meet the criteria, 5 or more of the following behavioral features must be met:

  • grandiose sense of self-importance

  • preoccupied with fantasies of unlimited success and power

  • special or unique and can only associate with high status entities

  • requiring excessive admiration

  • sense of entitlement

  • exploitative

  • lack of empathy

  • often envious of others and believes others envy him or her

  • arrogance and haughtiness

I would add that some narcissists are low-self esteem, but I believe he was a high self-esteem psychopathic narcissist.  

Machiavellianism

Machiavellianism overlaps with narcissism and antisocial disorders. They are more likely to deceive and manipulate others for their own personal gain. They see people as objects for use and manipulation. They will have normal amounts of empathy unless they have traits of psychopathy.

The opposite of machiavellianism are people who display honesty and altruism.

In viewing Ted Bundy, it is highly probable that he displayed high Machiavellianism with traits of psychopathy and narcissism—thus having all the dark triad.

How did Ted Bundy come to be this way?

Home-grown sociopaths don’t necessarily have a need to be seen and appreciated by others. They often have been made the way they are due to horrific abuse, and usually prefer to be left alone. But, psychopaths who are born with low physiological arousal, have more of the predatory aggression which we see in Ted Bundy.

A person with primary psychopathy can either choose to live in society and do things to help, although without empathy and with difficulty attaching to others. Or they can choose to do illegal things to get their drives met. Whichever one they choose will write their brain and pattern of behavior that they will follow. These people can be incredibly helpful to society or incredibly harmful.

Determinism versus free will

It often comes down to determinism versus free will. In other words, did he make the choices or did his mental illness cause them? Ted Bundy went to prison for the choices he made, not the psychological predisposition that he had. However, when one goes into determinism, they will blame others for the choices that they made.

It is important to remember these people do have a choice. Because, ultimately, there is another dimension here, which is the moral dimension. We all have the responsibility to others and to society.

However, there are people who have less choice than others. For example, a person with a frontal lobe injury will have less “choice” than someone who does not. Ultimately, choice must be in line with responsibility. But I have known people to “check themselves in” for desires to do bad things, and get help. Sometimes we only have a small choice to change our environment.

Treatment

With the Ted Bundy type of psychopath, therapy will most likely not benefit them. This type of person should be put in prison for life.

Therapists must be especially on guard with someone like this, which can be uncomfortable for therapists and clinicians. You must view your interactions with them like a chess match. Because, everything about your interactions is a game to them.

Towards their therapists, they may exhibit these types of behaviors:

  • Play into your desire to “make a difference,” which is fertile ground for them to manipulate you.

  • Express prosocial behaviors.

  • Trap you by making you believe you have reached them in a way no one else has.


However, the “baked” sociopaths, or those with features of antisocial behaviors, can benefit from therapy. Clients will very rarely be as healthy and whole as you want them to when they leave therapy.


However, the goal is for them to leave with better connection to people, not use sex as a coping strategy, be more intimate (non-sexually) with humans, and relate better to authority. This will lower their risk of sexual violence, and help them on a track to be able to fit into society.

Approaching therapy

You can give all the tests you want, but one of the most valid tests of psychopathy is the “hair on the back of your neck” test. You just know it when you’re in the presence of psychopathy. It will alarm your body’s natural detection mechanisms. You can just “feel” it. I know that isn’t technical jargon, but it’s so true.

The goal in therapy should be to change their mindset away from objectifying people. It is suggested that you get access to their large criminal history in order to learn what they have done and use that strategically in their treatment. This will arm you with the knowledge of what they have done and what they are capable of.

Approaching them with the idea that they are likely to continue their cycle of behavior unless they do something to change it is an ideal approach. Discussing the importance of change itself and how change occurs can be helpful.

Focus primarily on the dynamic risk factors or “stable factors”:

  • Issues with authority

  • Intimacy

  • Hostility and attitudes towards women

Targeting those aspects one by one and digging into each one is a strategic approach. Improvement in each of these areas will lessen their risk of continuing their behaviors significantly.

Final Thoughts

There will always be that one in a million person who will use their predisposition to harm others and create a life of criminal behavior.

However, the glamorization of criminals like Ted Bundy from the media tend to breed a culture focused on the fear of these one in a million criminals.

It is important to remember that the media carries a bi-directional quality. Where the consumer drives what the media will pay attention to. Limiting the attention we give these types of criminals will lessen their need to be publicized and noticed.

For Nate Hoyt’s extensive notes on this episode - go here

Questions, comments, thoughts? Please comment on the picture that corresponds to this post on my instagram: @Dr.DavidPuder




How to treat violent and aggressive patients

Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic

On this week’s episode of the podcast, I interview Dr. Michael Cummings. Dr. Cummings works at a state psychiatric hospital for the criminally insane, so he has extensive experience in treating patients for aggression and violence.

The different types of aggression

The words “aggression” and “violence” are sometimes used synonymously, but in reality, aggression can be physical or non-physical, and directed either against others or oneself. Violence is more of a use of force with an intent to inflict damage.

One study looked at the principle types of aggression and violence that occur in psychiatric patients, and broke it down into three categories:

  • Impulsive violence (the most common category)

  • Predatory violence (purposeful and planned violence)

  • Psychotically-driven violence (least common)

Within 5 state hospitals, 88 chronically or persistently violent patients with 839 assaults, the rate of impulsive violence was 54%, and predatory violence was 29%. Psychotically driven patients logged 17% of total violence (Meyers, M. Cummings et al., 2013). Studies show psychotically driven violence decreases the longer the patients are in care and medicated.

Predatory Violence

Predatory violence is what people typically think of when they think of psychopathy, or someone with antisocial personality disorder. It is violence with a purpose, and that purpose is usually to gain something. They typically show a lack of fear and very little autonomic arousal even when they are being violent.  The amygdala and the temporal lobe is underactive and the communication between them has a weak signal. People with predatory violence also have lower affective empathy.

Some of the early research done by Adrian Reign measured blood pressure, galvanic skin response and heart rate when showing neutral, frightening or peaceful pictures to children. Of those who lacked effective response or autonomic response to those pictures, 75% percent of those individuals became violent criminals by age 18. Interestingly, 25% of them became prosocial and entered jobs as police officers, bomb disposal experts, and so forth.

True psychopaths are a very tiny part of the population. About 2% of women score significantly on the psychopathy checklist. About 2-4% of men have elevated scores on the psychopathy checklist. Not all of those individuals, however, are violent, and many persons who are psychopathic are more interested in profit. Some become the crime bosses (not actually doing the violence themselves) and others end up in politics.

Impulsive violence

Impulsive violence or aggression is actually the most common, and in many ways the most complex, form of violence that occurs in a variety of mental illnesses, including:

  • psychosis

  • mood disorders

  • personality disorders

  • anxiety disorders

  • PTSD

It is essentially an imbalance in impulse generation and a failure of the prefrontal cortex to evaluate the impulse and weigh the consequences. All of us generate a variety of impulses, some good and some bad, including impulses driven by our irritability and anger.

In predatory aggression there is increased medial prefrontal cortex activity whereas in reactive aggression there is decreased activity.

What can cause impulsive violence to be an issue:

  • Traumatic brain injury

  • Some of the dementias including frontotemporal dementias

  • Anoxic brain injury

  • Intellectual disability

  • Personality disorders

  • Drugs

  • Drug detox

Psychotic aggression

Psychotically driven aggression is most often a result of delusional ideation or the belief the person holds that they are in some way being persecuted and being taken advantage of. Psychotic or mentally ill people do have an increased rate of violence compared to the general population. The mentally ill are responsible for around 5% violent crimes, meaning non mentally ill people are responsible for 95%.

Psychotic Delusions leading to violence

Ones study looking specifically at the first episodes of psychosis found that in about 458 patients, anger was associated with certain types of delusions that led to the violence (Coid, 2013).

The underpinnings of delusion-driven violence usually stems from when people have delusional beliefs that are persecutory in nature. When they believe that someone is out to get them, it removes inhibitions against acting out violently, because that person’s view is they are protecting themselves. Typically, this violence comes from the belief they are being spied on or persecuted.

Persecutory delusions associated with a command hallucination is a particularly potent precursor to violent behavior. If your delusion tells you your neighbor is the devil, and your command auditory hallucination is that God is telling you to “kill him and save the world from destruction”  it can lead to a very bad outcome.

IQ and aggression

There is also an association between the IQ and aggression (Huesmann, 1987).

A recent study in state hospitals looked at what correlated with persisting violence, and across all of the types of violent behavior, cognitive deficits (particularly impairments and executive functioning) were associated with elevated rates of violence.

Men are more violent than women

Men are likely more violent than women because they have historically been the hunters, which involves violence. Women were gatherers more often than not, and consequently, men have a standing evolutionary tendency toward more frequent use of violence. Women can be violent, but if you look at the rates of violence between men and women, men are clearly more violent.

The purpose of aggression  

You could say the healthiest outcome for our aggressive and violent impulses is when we use our innate ability to be aggressive to engage in things like a healthy competition. Or even to provide motivation and drive to achieve.

In the beginning, humanity formed tribes, and aggression allowed someone to climb up the dominance hierarchy within the tribe. It also allowed them to protect themselves from other tribes. It was basic for survival.

If we look at animal psychology, there is a lot we can learn about the aggression and dominance hierarchy, like how apes interact with each other, or form alliances. As a way of creating alliances, often an alpha ape will groom other males.  The violence comes out when the clans come against each other. When one ape is wandering from its clan, two apes from another clan may attack one single ape viciously.

In other circumstances, if a dominant ape is taken away from his clan for a couple of days and brought back into the clan, a couple of other apes may have formed a new alliance against the prior leader and attack him.

As human beings, we are also like this. Many of our social interactions and group structures have the same kinds of alliances and effects of absence can play out similarly. Of course as humans, we do have higher verbal centers, and philosophy or spirituality, that allows an individual to be less violent and to transcend their base instincts.

Aggression and autism

People with intellectual challenges most often exhibit impulsive violence, particularly those on the autistic spectrum. The person may have a greater difficulty processing or understanding their own emotions if there are significant intellectual deficits. They may also have elements of not being able to judge a response or to moderate a response. The general pathophysiology of the autistic spectrum disorder suggests that the connections between neurons and the autistic brain is not what it should be, and they are not differentiated so that information processing can be fragmented.

Treatment of aggression

Psychotic aggression treatment

Treating with an antipsychotic medication is helpful and decreases violent episodes. In one study, clozapine helped psychotic aggressive patients with executive dysfunction more, compared to using haldol or olanzapine (Krakowski, 2011).   

Psychopathic aggression treatment

A predatory-violent individual needs to be contained in prison if there is a demonstrated past of persistent violence.

There is evidence that by enhancing intellectual empathy, psychopaths will be less violent. There is also interesting research that by giving oxytocin, the hormone that increases affiliation and collaboration, may have a moderating effect on some psychopathic individuals.

However, in terms of psychopharmacology, we don’t have any specific medications to control that behavior. Some medications, such as clozapine, can affect the underlying issues behind psychotic behavior and thereby reduce it, but there is no direct treatment for psychopathic violence pharmacologically.   

Impulsive aggression treatment

Dr. Cummings discussed the use of Mood stabilizers helping in persons with borderline personality disorder, SSRIs and trazodone helping in dementing illness in the elderly and alpha 2 agonists in people with things like autism or TBI. Alpha 2 agonists (clonidine) can fool the brain stem into thinking enough norepinephrine has been released, then less norepinephrine is secreted, making the brain stem calm down.

Essentially, in an emotional disorder, if you change the affective (limbic) tone, you can decrease the likelihood of emotionally reactive aggression, for example, by using mood stabilizers lithium and divalproex.  

Using an antipsychotic, and not just a mood stabilizer, doesn’t show any benefit for traumatic brain injury patients. Antipsychotics have been used for people with autism spectrum disorder, and some evidence shows that drugs like risperidone can be helpful to control outburst issues. If there is evidence of sexual aggression (or aggression occurring at women after puberty), using an GnRH agonist—antiandrogen treatment—can sometimes be necessary).

Psychotherapy for aggression

There have been a number of anger management therapies that have been used over time. Therapists can help people be aware of their anger and manage their impulses, or push their anger and aggression toward a more prosocial response.

For people with borderline personality disorder, dialectical behavioral therapy, mentalization based therapy or transference therapy are important. For schizophrenic patients, a good therapeutic alliance is important to create medication compliance. I have touched on how to process anger in my microexpression series and will have future episodes focusing more on the psychotherapy approaches to anger.  

Overall in therapy, we must assume that our patients will lie to us sometimes because they are afraid, and double check to insure they are following our prescribed protocol. We must also work hard to build trust and a therapeutic alliance.

Final Thoughts

Violence and aggression deserve much more attention as a specialty than we have given it in the past. It is a major burden for family members and friends.

Please submit any questions you have and we will submit them to Dr. Cummings and to answer.

(In the podcast details about specific medications are discussed for psychiatrists who are interested in advanced psychopharmacology.)

Further reading:

Link to Ideal blood levels are found in Resource Library

“California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines”




How Empathy Works And How To Improve It

What is empathy?

Empathy is the ability to understand another’s state of mind or emotions. It is also is being able to feel, understand and share with someone else in what they are saying, their meaning of life, their motivations and values.

In research there are 3 types of empathy that are commonly described: cognitive, affective, and compassionate.

Cognitive empathy

Cognitive empathy is also known as perspective taking, and it can help someone understand another’s personal experience. It also tends to reduce interpersonal aggression. Cognitive empathy is exactly what it sounds like—cognitively understanding someone’s situation, emotions, and motivations. When we understand someone else, we are more likely to view their behavior as similar to our own.

  • One study of Asperger syndrome showed they had lower cognitive empathy but NOT affective empathy. (Dziobek, 2008)

Affective empathy

Affective empathy is about a shared emotional experience, one of feeling together. It uses the mirror neuron system, which I will discuss later on in the article. Affective empathy forms powerful emotional relationships.

  • Boys with higher aggression had ½ the affective empathy, but the same level of cognitive empathy, as the non aggressive control group (Schechtman, 2002)

Compassionate empathy

The third form of empathy is compassionate empathy, which is also called empathic motivation, prosocial concern, or sympathy. This is when you feel moved to help another from how to experience their reality.  

The science of empathy

Mirror Neurons are sharing neurons

Our brain has neurons solely designed to mirror other people. From birth, when we focus on another's movements, emotions and intentions, our brain lights up automatically, and largely unconsciously, around 10% the same way. Our own body-state can be derived from someone else outside of us. We can therefore understand and map out the mind of others by placing ourselves in a comparable body state. This process is important for empathy, intuition, transference, countertransference, enactment, projection, internalization and intersubjectivity.    

The discovery of mirror neurons:

In 1992, while studying a monkey's brain with electrodes attached to the motor area (the area that lights up when movements by the body are made), researchers accidentally discovered that not only would the neurons become activated by the monkey reaching out to pick up a piece of food, but also when the researchers made a similar movement. Later, the same team published a paper that showed that there were mirror neurons responding to mouth actions and facial expressions. Further studies confirmed that around 10% of neurons in certain areas of a monkey's brain had mirror abilities. Later, these studies were expanded to humans.  

Current research:

A recent study summarizing the data of 125 fMRI studies of humans (brain imaging that shows what is active), found that there were many areas of the brain with this capacity. (Molenberghs, 2012) Beyond seeing actions performed by others and having them represented in our brain, there are 3 other areas of the brain that are activated in a similar fashion:

  • Ever wonder why watching people embrace enthusiastically at an airport is fun? When you observe someone being touched, a similar area in your brain (the secondary somatosensory cortex) activates in a similar way as the person being touched.  (Keysers, 2004)

  • When you only hear something, like someone cracking open a peanut, how do you know what is occurring? Another study showed that there was a similar brain circuit firing in both doing the action and hearing it, and just hearing it. This study also showed that those with higher scores on perspective taking (ability to slip into another's shoes) had stronger activation of mirror areas! (Gazzola, 2006)   

  • When we watch someone grieve at a funeral, ever wonder why we feel their sadness?  When you feel emotion, you experience the emotion in your brain, like they are to a lesser extent.  (Gaag, 2007)

    • When normal college students looked at photographs depicting emotions, out of their awareness their own face muscles depicted the same emotion on an EMG.  

    • “We are hard-wired to feel what other experience as if it were happening to us.” (Marco Lacoboni)

    • We used to say, metaphorically, that ‘I can feel another’s pain.’ But now we know that my mirror neurons can literally feel your pain.

    • “Mirror neurons dissolve the barrier between you and someone else.” (Vilayanur Ramachandran)

Now researchers are saying that the mirror neuron system is involved with:

  • Understanding another's actions and intentions

  • Neural basis for the human capacity of empathy

  • Learning new skills by imitation and rehearsing

Non-empathic types—the Dark Triad

The “Dark Triad” refers to three types of disorders that cause people to have low empathy for others. The big common denominator for these people is a deficit in affective empathy, but after matching for primary psychopathy, the others are no longer predictors of low affective empathy (Wai 2012). The Dark Triad consists of: narcissists, Machiavellians and psychopaths. People who have narcissistic traits and machiavellian traits often have some primary psychopathy traits as well.  

Individuals high in narcissism had positive feelings when looking at sad faces and were accurate at recognizing anger (higher cognitive empathy may be bias at grandiose self reporting). Individuals higher in primary psychopathy (they can usually maintain cool composure and carefully execute planned behaviors with a lack of morality, whereas those with secondary psychopathy respond to their negative emotion when they harm others) felt positive when looking at sad, angry or fearful images and more negative when looking at happy images, and were rather inaccurate at identifying all emotions.

Machiavellians felt negatively with happy images and positively with sad images, while they tended to inaccurately identify happy or sad emotions.

Empathy and the medical field

  • Studies show that empathy declines in third year of medical school (both for men and women, but women are higher in empathy in general)  (Hojat, 2009) but that doctors can also increase their empathy through certain practices. (Riess, 2012)

  • In a study of 20,961 patients, primary care providers with high empathy have been shown to have lower rates of metabolic complications compared to moderate to low scores (4.0 per 1,000 patients vs 7.1 and 6.5 respectively) (Canale, 2012).  

  • There have been many studies that show both cognitive and affective empathies ability to change patient care when high and low empathy are demonstrated. For example, there is a correlation to a doctor’s ability to more accurately diagnose depression and anxiety, understanding interactions, more positive patient outcomes, increased therapeutic alliance, more patient satisfaction, and fewer malpractice claims. Doctors who showed higher empathy were more likely to have their HIV patients take their medications (Flichinger 2015).

Research on “Therapist Effect”

  • Some doctors or therapists have better outcomes. Empathy seems to be important in therapist effectiveness and can be increased.  

  • Different studies show outcomes vary between patients, of which 5-12% can be attributed to a particular therapist.   

  • One study of 91 therapists over 2.5 years: the best therapist showed a change of 10 times the average mean, the worst showed the an average increase in symptoms.  (Okiishi, 2003)

  • Higher interpersonal skills has been linked to better outcomes when studying therapist effect. (Anderson, 2009)

  • Higher-empathy therapists have higher success regardless of theoretical orientation. Lower-empathy therapists linked to higher dropout rates, relapse rates, and weaker therapeutic alliance. Empathy was shown to have an effect size of 1.22-1.43 when independent observers rated empathy for substance use outcomes. (Moyers, 2013)

  • In a big study on therapist effect (69 therapists, 4,580 patients), they found that years of experience, gender, age, profession, highest qualifications, caseload, degree of theoretical integration did not predict outcome. The amount of time spent targeting improving specific skills and reviewing therapy recordings predicted client outcome.  

Can we improve our empathy?

Studies show that we can. Here are some things that can improve your ability to empathize:

  • Optimize your sensorium—keep yourself healthy. When you are tired, hungry, chronically stressed and with poor focus, it will be harder to enter into the experience of another.

  • Try to understand the person’s emotions that you are with.

    • A study showed by trying to pay attention to emotion mimicry was increased (linked to affective empathy)

  • Read fiction (Bal, 2013) allow yourself to be transported into the book.

  • Work through our “countertransference”

    • Talk through difficult situations

    • Patients have different ways of relating—learning to understand others, to see their way of being as “adaptive,” can be empathy promoting.

  • Learning to read emotions and body language more accurately  

  • Learning to accept feedback

  • Calming your own hyperarousal through practices like mindfulness

  • Tuning your mirror neurons

  • Noticing when connection or disconnection is occurring

  • Practice empathy towards viewpoints that are not your own

    • Becoming mindful of the emotion, the distress, the meaning behind the distress

Can therapists lose our empathy?

Studies show we can experience empathic strain and rupture. Empathic failure may lead to aggression. It is hard to empathize when we feel subjected to powerful influences from patients: complaints, requests, accusations, subtle seductions, bits of blackmail, challenges.  Throughout history, rulers have decreased empathy in their warriors and people by stirring up disgust towards those they seek to kill.

We are more likely to empathize with those we interact with frequently, find similar to us, or find thoughtful and kind.  We need to humanize people’s actions and see them like us, to not lose the part of us that could consider that we too could be in their situation.

Consider the stages of empathy:

I think of empathy in terms of 3 categories: the moment to moment emotional experience, the meaning and context of the emotion in their life, and the subjective experience evoked and created by the unique connection I am having in the here and now with the person.  

Level 1: There are moment to moment flashes of emotion on someone’s face, changes in body language, and current distress. Empathy can be experienced by just witnessing a flash of emotion and allowing the person to know you see it and that you hear them. During this, we can try to understand the person’s emotions, and ask them to verify what they are feeling, if we are correct in our questions, such as if they are feeling sad or angry about something.

Tuning into their experiential state and then asking if you are on the right track: (note if the patient gives a different word then do not contradict) can be helpful.

  • Ask them a few questions to clarify:

    • Perhaps you feel happy?

    • Perhaps you feel frustrated?

    • Perhaps you feel sadness?

    • Perhaps you feel disgusted?

    • Perhaps you feel concern or fear?

    • Perhaps you feel a sense of pride?

    • Perhaps you feel disconnected or numb?

    • Perhaps you feel a sense of embarrassment or shame?

  • Use their own words and repeat what you hear from them:

    • Patient: “I just feel so tired and sad all the time.”

    • Doctor: “It makes sense you feel tired because you have been so busy with your new jobs. In light of your recent losses your sadness also makes sense.”

  • Matching rhythm of voice, tonality, emotionality.

    • Matching an infant's cry rhythm (but not intensity) calms and regulates the infant

  • Imitation

  • Recognition of what the patient hopes for:

    • I hear you have hopes for… desires for… dreams for… aspirations for...

Level 2: This is where we try to know the context of the flash of emotion, the distress either in the distant past (how early relationships informed it) or recent life situations. Sometimes the quantity of distress is only as high as it is because it is linked to prior loss or prior trauma. We can find the context of the emotion by matching their emotionality, their demonstration of emotions on a level that we feel is appropriate. We can look at the meaning of the emotion and the context of the meaning of that emotion in their lives. We can also empathize with the meaning of the emotion once they’ve identified its context.

Even if they flash anger towards themselves, but maybe they in doing that are not accomplishing the energy of the emotion, and they are missing how the anger can help them accomplish their goals. Thus when the anger is pointed at themselves, we can explain that the anger should be pointed outward, and give energy to action.

  • Example: anger towards self looks like, “I am worthless” instead of anger towards abuser: “he should not treat me like that, I will set up a boundary.” The empathic statement can be “it must be hard to feel the anger pointed at yourself, telling you that you are worthless, and perhaps although it was adaptive to do this growing up, makes it hard to set boundaries now.”

Level 3: This level is when the person is having emotion that occurs because of their relationship with you. It is the interpersonal, and commenting and empathizing with any distress (or positive emotion) that your relationship is creating is a level 3 empathic statement. When a patient demonstrates anger towards their therapist, it’s helpful to ask if they are feeling anger towards you and if they feel comfortable talking about that emotion.

We can create psychological safety for a patient to give feedback to us by telling them we like to hear what they are feeling towards us. For example, my mentor, Dr. Tarr, tells his patients:  

“I very much want to hear your positive and negative feelings, particularly about me, and particularly negative ones. It will be helpful for you to share any feelings of disappointment, feelings of not being understood, feelings of not being responded to or criticized, or mannerisms or things I say that affect you undesirably. I hope you can understand that this is not a usual social situation, where you don’t tell people negative thoughts, here I hope you have the courage to say them out loud. It will be very helpful to say it has it is happening; we can learn much more than if it comes out later; we know it’ll be hard—but this kind of a laboratory where we discover what goes on between us.”



Understanding Placebo

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On this week’s episode of the Psychiatry and Psychotherapy podcast, I interview Mark Ard, M.D., a third year psychiatry resident at Loma Linda University. On the state level, he works towards developing means of access to care, in-patient psychiatric care, affordability of care, and further access to mental health.

Mark is also the person who encouraged me to start pursuing weight training through Starting Strength, which we will link in this article.

Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic

Understanding Placebo

David Puder, M.D., Mikyla Cho, Mark Ard, M.D.

What is placebo?

The original meaning of the word placebo is, “I will please.” That statement comes from a time when doctors didn’t have our modern code of ethics, and they would prescribe whatever would make the person feel better. They probably had the best intentions, but they also would have known that whatever they were prescribing might not have been a real medication for the symptoms the patient was experiencing.

Doctors, even then, knew that suggestion was powerful, sometimes more powerful than the medicine they were prescribing.

Laypeople who hear the word “placebo” automatically think of sugar pills. They may think only that it’s something a doctor gives to placate and make people feel better when they aren’t getting the active medication. Placebos have long been used as a comparison arm for clinical trials. Usually it is in the form of an inert sugar pill or sham-procedure. Researchers can observe a psychobiological response known as the placebo effect.

But when thinking about the word “placebo,” we must think of the entire effect of it, and it is perhaps better termed “the meaning effect.” As I discussed in last week’s episode of the podcast, the meaning we give something creates belief, and belief is a potent change mechanism, even when it comes to our physical health. It is especially potent when it comes to mental health.

The placebo effect encompasses the therapeutic alliance, expectations, natural healing of the body and mind, and the environment of therapy. It involves the power of suggestion, mood, and the beliefs behind even one positive or negative interaction with a doctor. It also, as we will see, involves studies involving heavy-hitting medication.

When there is an increased ritual, there is an increased placebo effect. During a hospital stay, the surgery preparation, meetings with doctors, nurses and therapists can have an incredibly therapeutic effect on a patient. It is possible to see biological mechanisms triggered by psychosocial context and attribute it to a placebo effect.

What is the power of suggestion, the meaning effect, placebo effect, and how do we use it or avoid it in our practices and when testing new medical treatments?

Why do we study placebo?

We study placebos because we need to understand how meaning works, how belief works, and on the other side, if a medicine actually works.

As doctors, we need to be able to read studies critically, with an eye for placebo. We need to see what actually works and what the study was controlling the treatment group to. We also need to know if there parts of the treatment that are working only because of the placebo effect, and if so, how do we use that to heal people.

How does the placebo effect work?

The efficacy of the placebo goes up because of the expectation and meaning we give to placebo.

In one study, half of the patients got the actual medication, half got the placebo. In the same study, in another group, 25% of the patients got the placebo, and 75% of them got the actual medication. In both of these studies, the participants were told the percentage chance they would get the real medication. In the study where only 25% of patients received the placebo, more people experienced positive changes from the treatment, whether they received the placebo or not. Most people believed, because of hearing the percentages, that they would probably get the medicine. That belief increased the placebo effect.

In groups with lower percentages receiving the actual medication, the response is lower, even with real medication.

Researchers think placebo effect works because of expectation and classical conditioning mechanisms. Such understanding may be an oversimplification of a very complex phenomenon but it provides a useful framework. Expectation is how much the patient believes in the therapy. Higher expectation leads to hope and positive outlook, which results in better outcomes. Exactly how this works is still under investigation. There are multiple theories as to the underlying mechanism, but overall, we can say that there is a bidirectional interaction between expectations and emotions, and we respond better when expectations are high and our mood is good.

Classical conditioning contributes to the placebo effect by modulating conscious expectation and non-conscious learning. The white coat effect is a classic example of how our body responds to a conditioned stimulus. Also, when a patient feels better after taking a pill, it becomes a conditioned stimulus, and the body may respond positively even after taking a placebo medication because of its conditioned response.

Expectation can be shaped by many factors. Broadly, these factors can be grouped into patient effect, clinician effect and study design effect. Patient effect refers to patient characteristics such as beliefs, values, cultures, and the meanings associated with the illness and the treatment.

In a study of IBS patients, Vase et al found that expected pain levels and desire for pain relief accounted for up to 81% in the variance in visceral pain intensity. There is also a greater dopamine release in patients who had higher expectation. (De la Fuente-Fernández). Conversely, pessimists were more likely to have negative side effects (when compared to optimists’ responses) when told a placebo would make them feel bad.(Geers)

How a patient interprets and generates meaning in a given treatment condition is widely variable and difficult to control for. A similarity in demographic characteristics would not account for all of them. Direct-to-consumer (DTC) advertising of antidepressants is an example of how a society can shape one’s view and expectation of the illness and the treatment. The promotion of antidepressants inherently depends on the biological model of depression. By simplifying depression as serotonin deficiency, antidepressants were promoted as a simple solution to a complicated problem. These advertisements are designed to convey that “psychopharmaceuticals have an obvious, objective, and scientific relationship to the symptoms they are supposed to treat”(Greenslit, 2012). The reality is more complex and difficult to understand than the advertising, but the narrative is believed and shapes decision making.   

An interaction with a clinician can shape the expectation of outcomes as well, especially if there is a strong alliance. Warmth, empathy, duration of interaction, and communication of positive expectation may significantly affect clinical outcome (Kaptchuk).  

One article (Verhulst et al., 2013) deconstructed the correlation between the medical alliance and placebo. The placebo effect encompasses the beliefs, values, and expectations that patients have about a treatment. We can help shape a patient’s belief and expectations by giving realistic illustrations of the treatment, which are more valuable than false hopes; this is the medical alliance that we as healthcare providers can utilize. Part of the medical alliance is the idea of concordance between the physician and patient. There is both narrative concordance, the shared understanding of the patient’s condition, and the relational concordance, the shared relationship structured based on scripts, boundaries, and interactional rules. Ultimately, by utilizing the idea of concordance and a strong alliance with the patient we can influence how they view a treatment and better the outcomes via the placebo effect.

Study design can also change expectation. Having a higher chance of being assigned to the treatment group and having a choice (Rose 2012) increases the expectation. The degree to which placebo resembles the treatment is another important consideration, because unblinding can lead to decreased expectation. (Some studies utilize active placebo to make unblinding more difficult.) In pharmacological studies, active placebo usually contains some real medication that contains some of the expected side effects to imitate the expected treatment.  

The mechanisms that control placebo effect:

  • Opioid system

This system bolsters a lot of the evidence for pain relievers—you have more of a placebo effect on the patient if they know they're getting the medication than if it’s snuck into an IV. The opioid system in the brain begins to work as a pain reliever before any actual medication sets in, if it’s even administered.

  • Dopamine system

Dopamine signaling is involved in expectation and response. Our brains will respond as if something is happening if it believes it will happen. This pathway is also involved in habit formation and novelty seeking. The brain lights up in the same way to a placebo as it does to an active intervention. There is a fascinating link between dopamine deficiency and Parkinson’s disease; placebos can induce dopamine release, leading to improvement in Parkinson’s disease motor dysfunction.

In another study, people were told they were getting either a cheap medication or an expensive medication. Even though they both received placebos, the group who was told they were getting the more expensive medication experienced a greater placebo effect.

Even the color of medication can affect a person’s response. Brand names can affect a person’s response. A person who is told they are receiving an anti anxiety medication will calm down, even if it’s a placebo.

  • Prefrontal cortex

The third “system” is prefrontal cortex, which is involved in associations and meaning. This is also one of the main areas involved in improvement of depression (Murray, 2013).


What is the effect of placebos on the medical profession?

Is placebo testing accurate?

Some industries fail to examine things with an accurate and rigorous placebo. For example, in a recent study on Botox used for depression, ¾ of the subjects knew if they had received the placebo or not (Finzi & Rosenthal, 2014). Some studies also neglected that placebos can actually change brain chemistry, and activate or deactivate different areas of the brain.

We often think that the patient who is administered a placebo, in taking the medication, thinks it is real and thus the whole placebo response is merely from taking the pill. But in those results we neglect the human factors that come into play when a person meets with a psychiatrist that is doing the patient interview, and how it could be the therapeutic alliance and feeling cared for that influences outcomes and spontaneous remission of symptoms.

For the medical field to determine that it’s not only the placebo effect taking place, that the medicine or treatment actually works, many factors come into play.


Discussing negative side effects with patients

How do you talk about medication as a doctor without scaring the patients with a side effect list? Studies show that by listing side effects, people are more likely to experience the side effects.

I usually discuss the side effects with patients if they occur in more than 1% of patients or if the side effect is life threatening. Also, if the patient feels like they need to stop the medication, I tell them to call or email me. Even knowing they can reach out of they are experiencing problems gives patients a sense of peace, and could decrease negative placebo effects of the medicine, and increase positive effects of it.

In medical education at large, there seems to be a loss of the science of connection and a focus on medicine rather than being able to emotionally connect to people, and mental health is part of the human experience.


Therapy and the placebo effect

Placebo and psychiatry have an interesting and complicated relationship—both are concerned with the mind-body connection. Using placebo in psychiatriatric research is, therefore, more challenging. It is more difficult to tease out the true effect of a treatment since mental illnesses have significant psychosocial components.

Higher therapeutic alliance, higher empathy, and higher interpersonal skills all have better outcomes. Beyond the model of therapy, each therapist’s kind of connection to their patients deeply affects a patient's’ response.

The value of the therapeutic alliance can be as powerful as medication, and also bolster the effectiveness as the medication itself.

In their paper Wampold, Frost, and Yulish (2016) reviewed the history of how placebo was used in randomized control trials for testing the efficacy of psychotherapies. They found that when poorly designed placebo therapies were used as controls, the psychotherapy treatment group had superior results. It is difficult to have a truly controlled placebo. For example, it can be obvious whether a therapy is a placebo or a true psychotherapy and the providers administering the treatments would also know which was the true treatment. People have advocated that different psychotherapies are beneficial because of their common factors such as the therapeutic alliance, discussing expectations, and instilling hope. These and other factors common to the variety of psychotherapies can also be found in the placebo effect, which facilitates the argument that placebo psychotherapies are not inert. Therefore when we look at studies that compare psychotherapies to a placebo therapy, we must be aware that the comparisons may not be completely accurate.

In therapy practice there are no effective placebos to be given to compare, so effect size with therapy is very different than effect size with medication vs placebo. A broader and more nuanced understanding of the placebo effect is important in two ways. First, it allows a clinician to critically evaluate studies that compare the treatment with placebo. Placebo should be evaluated within the framework of mental illnesses. Secondly, understanding placebo allows a clinician to maximize the clinical outcome by focusing on factors such as alliance. Placebo teaches us about the complexity of the mind body connection, and calls for a more integrated approach in treating mental illnesses.

The effect size in double blind studies, however, does not tell the whole story of the effectiveness of the psychiatric relationship, because it does not take into account the part of the placebo response that actually came from a psychiatrist’s relationship with the patient.

Even since the beginning of psychopharmacology, in the 1940’s, placebo effect has increased. In part, I believe that’s because we’ve reduced mental illness to a few symptoms and then say those can be helped or fixed by a pill. For example, there is commonly believed language around depression that says it’s a serotonin deficiency. So, patients take medicines to boost their serotonin (SSRI medication). That is not the only thing going on in depression, and it’s not necessarily true. So SSRI medications have a large placebo effect.

Further, different psychiatrists will have different effectiveness with patients (McKay, 2006). The authors analyzed data from the Treatment of Depression Collaborative Research Program (TDCRP) that compared imipramine hydrochloride with clinical management vs. placebo with clinical management and found that 7% to 9% of outcome variabilities depended on the psychiatrist providing the treatment. When using BDI, the results were statistically significant (p < 0.05) and when using the HAM-D the results were marginally significant (p = 0.053). Therefore the authors concluded that the psychiatrist effect was at least equal to or greater than the treatment effects. The effectiveness of a psychiatrist is also critical in proving optimal treatment.  


Non-therapeutic medical fields and doctor-patient relationships

Even the awareness that the placebo effect exists should make medical workers understand that we need to consider people’s outside lives, not just the psychopharmacological effects of the medication. If little things have a placebo effect, and that is directly related to meaning and belief, what are the patients experiencing outside of the medical office that is influencing them?

Conclusion

Our brains were made to create meaning out of things, and this meaning can change the very nature of the brain. When we understand placebo we become better guides to our patients, steering them away from things that don’t do anything, and towards things like having a connected relationship with a caring person, which can be the treatment itself. We also look not only at how powerful a medication was compared to the placebo, but also if the patients thought they were taking the real medication or not. We also learn that belief is powerful and can understand how people get swayed into cults and taking things which have been proven to only be harmful.  

Perinatal Mood and Anxiety Disorders

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In this podcast and article Dr. Kelly Rivinius, a licensed clinical psychologist who helps women suffering from PMAD, gives her insights about PMAD, its risk factors, prevention, and her own experience with perinatal OCD and anxiety.

David Puder, M.D. and Kelly Rivinius, Psy.D. have no conflicts of interest to report.  


Article the accompanies this episode go: here

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