Ethics and Boundaries David Mays MD Ph D

Ethics and Boundaries David Mays, MD, Ph. D dvmays@wisc. edu

The Biological Basis of Ethical Behavior

A Brief Review of Ethical Decision Making • Ethics is a branch of philosophy that involves the analysis of the moral value of judgments and duties. • Interest in ethics as a field of study has ebbed over the centuries, but has been revived in no small part by the growth of biomedicine in the second half of the 20 th century. • Today most ethical discussion is framed as a contrast between three ethical systems: deontology, utilitarianism, principlism.

Deontology • Deontology is an ethical system based on duties and moral obligations. Religious laws generally impose a set of obligatory behaviors that are right or wrong in and of themselves, regardless of the consequences. Religious “commandments, ” Kant’s “categorical imperative” are behaviors that are universally binding. – Tell the truth – Prohibitions against abortion, transfusions, divorce, murder, eating certain foods, etc. – Love your neighbor – Etc

Utilitarianism • Utilitarianism states an act is morally right if it imposes the greatest benefit and imposes the least burden on those involved. The end justifies the means. However, it is often very difficult to calculate the consequences of particular decisions. – Lying is morally correct if it saves a life. – Killing may be justified for a moral cause, like self-defense or in a just war. – Stealing to get food for your family is part of a higher duty.

Principle-Based Ethics • Principlism is an attempt to reconcile the discrepancies between utilitarianism deontology by tying moral decisionmaking to certain principles. This is what is usually taught in ethics seminars. It is not strictly a theory and it is intrinsically vague. It is also not hierarchical. It is an effort to make ethics more practice friendly. • Four principles often used in medical ethics: – – Non-maleficence Beneficence Respect for autonomy Justice

The Train Problem #1 • An out-of-control train is racing toward five hikers, who are unaware that it is coming. Adam is standing by a switch and can send the train down a side track, where one hiker is hiking. • Is it morally permissible for Adam to switch the train?

The Train Problem #2 • An out-of-control train is racing toward five hikers, who are unaware that it is coming. Hitting a large object will cause the train to stop automatically. Beth is standing on a bridge over the track, beside a large man. • Is it morally permissible to push the man onto the track, stopping the train?

Moral Dilemmas: Other Examples • You are a surgeon in an ER. Five people arrive in critical condition, needing - 2 needing kidneys, one a heart, one a liver, one a lung. A healthy young person is waiting to give blood. Should you take the organs from him? • You are driving a car in the fog. Suddenly there are 5 people standing in your lane. There is one person standing in the other lane. Should you swerve and hit the one person?

Moral Luck and Other Puzzles • Different outcomes for the same behavior move us to impose different consequences, even though the only difference is bad luck. • Drunk driving example – How wrong was it to drive drunk? (both equally wrong) – How bad is the character of each person? (both equally bad) – How much punishment? (different)

Moral Luck and Other Puzzles • Why should outcomes matter only for punishment? – Humans learn better when they have consequences for their behavior, even if it isn’t in their control. • However, intent does matter for consequences, as well. Beginning at 4 years old, intent gradually becomes very important. In adults, it is the most important. Sort of. Moral luck continues to operate around the edges of morality. • The ability to perceive intent is in the temporo-parietal junction.

Right Tempero-Parietal Junction • The temporoparietal junction (TPJ) is an area of the brain where the temporal and parietal lobes meet, at the posterior end of the Sylvan fissure. This area is known to play a crucial role in self-other distinction (our body in space) and theory of mind. Damage to this area has been implicated in producing out of the body experiences. It is also the spatial location of auditory hallucinations in schizophrenia. • Electromagnetic disruption here has been shown to impair individual’s abilities to make moral decisions!

Moral Dilemmas - Research • There is no evidence that straightforward deontological, utilitarian, or other rules account for the differences we see in the train problems. • People are confident in their judgments but are largely clueless and incoherent in trying to explain why they decide the way they do. • There is strong emotional input accompanying the decision. This emotional contribution is probably shaped by an individual’s culture, and may serve to reinforce action.

How Do People Make Ethical Decisions? • We know that ethical knowledge does not necessarily result in ethical behavior, and that multiple personal and interpersonal influences affect the decision-maker. • We know that models of ethical decision-making all face the problem of trying to explain something that is both familiar and common, and whose mechanisms are mysterious and complex.

Jonathan Haidt • Haidt argues that rather than reaching moral judgments by reasoning and reflection, people grasp moral truths automatically through intrinsic moral intuitions. Moral reasoning is used to justify the decision and influence other people. When people “reason”, they take different perspectives, activate new feelings, and weigh the feelings against one another.

The Template for Morality • Harm/Care – empathy, concerns about violence, compassion • Fairness/Reciprocity – social contracts, equality, rights, justice • Authority/Respect – obedience, duty, respect for superiors • In group/ out group – loyalty, betrayal • Purity – Intuitions of divinity, mind and soul, moral disgust

Empathy • A newborn baby, barely able to see, can imitate the facial expressions of adults within 1 hour of birth. • Empathy is a kind of contagious emotional expression. As adults we speak and gesture in the same way as the person speaking to us.

Monkeys and Raisins • In 1997, four investigators from the University of Parma were studying the electrical activity of small motor tasks in the brains of macaques. One researcher walked into the room and picked up a raisin and ate it. He happened to be looking at the monitor and saw the electrodes firing indicating a motor activity. Investigation showed the same pattern as the raisin picking activity.

Mirror Neurons • The firing neurons were called “mirror neurons. ” The next question was whether mirror neurons exist in humans. • The answer is yes, but they are more widely distributed in our brain, including some areas that have nothing to do with movement. • A region full of mirror neurons is Broca’s area.

Broca’s Area • Mirror neurons in Broca’s area light up: – When the subject performs an act – When they see someone else perform the act – When they hear a description of someone performing the act • Is this a key to how human language emerged?

Mirror Neurons • Neurons in the pre-motor cortex show the same level of activity when an individual reaches for an object as when he watches someone else do the same. • This also occurs when subjects imagine an action. • Recent research indicates that this system activates when we see others experiencing a disgusting event, or pain. It may underlie the experience of empathy.

Mirror Neurons • Mirror neurons fire involuntarily. Their firing patterns encode not just movements, but the meanings behind the movements. • They are identical to other neurons under a microscope, but they have a enormous number of interconnections. They may continue to expand these connections throughout life. • And like other capacities, they differ among people.

Mirror Neurons and Empathy • Subjects with higher empathy scores on psychological testing exhibit stronger mirror neuronal reactions to facial expressions of disgust and pleasure. • Psychological tests of children indicate strong correlations of mirror neuron activity with empathy scales, not with cognitive scales.

The Challenge of Living in Communities • Functioning in a social context requires us to react to others, understand the other’s emotional perspective, and separate one’s own response from the other’s response. • Mirror neurons fire automatically, allow us to infer intentions, and fire more robustly when we perform the action ourselves than when it is observed.

The Challenge of Living in Communities • Mirror neurons may represent an experience-based, nonreflective, automatic form of understanding another mind. We can understand their intentions and predict their future behavior. And at the same time, we can maintain a sense of self-identity. • Interdependence becomes possible.

Empathy Today • Empathy is not only an innate capacity, but it is also cultivated by experience. Empathy levels have been falling among college students over the past 30 years. The last 10 years have seen an especially steep drop. (Not surprisingly, self-reported narcissism in students has reached a new high. ) • No one knows why this is happening, but it is accompanied by a sharp decline in reading for pleasure among this group. People are also more likely to live alone and less likely to join groups.

The Dictator Game • Player 1 is given $10. • Player 1 offers some amount of money to Player 2.

The Dictator Game - Results • Many players offer nothing, but some offer $5. • People who play repeated games with identified people develop a reputation and generally give around $5.

The Ultimatum Game • Player 1 is given $10. • Player 1 then offers some amount to Player 2. • If Player 2 rejects the offer, nobody gets anything.

The Ultimatum Game - Results • Players punish unfair offers even at personal cost. • Responders universally reject offers at $2 or less.

Jonathan Haidt, Ph. D • Communities that punish citizens for breaking the rules have more cooperation among their members.

Brain Studies of Fairness • When reciprocity fails, or the offer is unfair, imaging studies reveal significant activation of the anterior insula, which plays a role in negative emotions such as pain, distress, anger, and disgust. • When players engage in punishment, the caudate nucleus is activated, a key center for pleasurable experiences.

Fairness • Notions of fairness permeate almost all aspects of life. It is universal among all cultures. Human beings have the innate capacity to monitor fairness: – – – Some ability to keep tabs To place values on different things To judge when an inequity has occurred To distinguish accidental from intentional giving and reneging To determine if an unfair act is worthy of retribution

How is the Notion of Reciprocity Possible? • • • Innate sense of fairness Strong sensitivity to and memory for “cheating” Intuitions about trustworthy people Commitment to revenge Moral emotions: – Warmth toward kindness, giving – Guilt

Logic and Social Specialization • Most people find the first problem is harder than the second. • Social contracts tap a specialization that is present in all human beings. Our minds have evolved a unique specialization to understand social contracts and to detect violations. • This kind of thought operates unconsciously and automatically. The ability to detect cheaters is found even in young children.

The Family • Genetic relatives are more likely to: • • Live together Work in each other’s gardens Protect each other Adopt each other’s orphaned children • Genetic relatives are less likely to: • Attack and kill each other • Those outside the “family circle” are less likely to be incorporated in the culture’s “moral thinking” - i. e. morality does not apply.

nation community extended family self

Moral Disengagement: Social Cognitive Theory • When people act contrary to moral standards, they activate disengagement mechanisms to avoid negative selfcondemnation. Moral disengagement is a cognitive process by which a person justifies his harmful conduct by loosening self-regulatory mechanisms. People rationalize or justify harmful acts against others. • Eight different mechanisms are typically used.

Mechanisms of Disengagement • 1) Moral justification: the harmful behavior is transformed into virtuous behavior (hiring young children for work overseas is better than what might happen if they couldn’t work) • 2) Advantageous comparison: comparing the harmful behavior to more inhumane or immoral behavior (I just took a little money. Some people stole a lot. And it’s not like I murdered somebody. )

Mechanisms of Disengagement • 3) Euphemistic labeling: using sanitized language (collateral damage, wasting (killing) the enemy) • 4) Displacement of responsibility: actions are viewed as the result of social or authority pressures (I had to steal because I didn’t have a job. I was just following orders) • 5) Diffusion of responsibility: acting collectively obscures individual responsibility (Everybody does it)

Mechanisms of Disengagement • 6) Disregarding or distorting consequences: reduces degree of guilt or shame (the insurance company won’t miss the money) • 7) Blaming the victim: obscures personal responsibility (I wouldn’t have taken the money if you hadn’t left it sitting on the counter) • 8) Dehumanization: victims are stripped of human qualities and are viewed as objects (redskins, japs, kikes, chinks, etc)

Moral Disengagement: Cognitive Distortions Theory • Three cognitive distortions are seen as leading to antisocial behavior: – 1) Causal attributions – blaming people and factors outside the self – 2) Minimizing/mislabeling – understating the consequences of the behavior and/or using dehumanizing labels – 3) Attributing hostile intentions to others, expecting the worstcase scenario for a social situation – (people are just waiting to take advantage of me)

How Likely Are We to Disengage? • Empathy inhibits moral disengagement. • Cynicism makes disengagement easier. • Those who believe strongly in fate are more likely to disengage. • Those who think of themselves as moral people are less likely to disengage.

Philip Zimbardo’s List: The Lucifer Effect • • Mindlessly taking the first small step Dehumanizing others Anonymity Diffusion of personal responsibility Blind obedience to authority Uncritical conformity to group norms Passive tolerance of evil through inaction or indifference

The Moral Emotions • Pleasant emotions: • • • Awe Gratitude Love Compassion Acceptance • Uncomfortable emotions: – – Guilt Shame Regret Remorse

Moral Emotions • When emotions become involved in our beliefs, it may involve us ascribing “sacred” status to what we think. • A sacred value is more than just a strongly held belief; it is a moral stance on which the believer will not budge, no matter what the conditions. Examples may include “the right to choose, ” “the right to life, ” the belief that sharia (Islamic law) must be the law of the land, etc.

“Sacred Beliefs” • Studies show that when people are offered money to relinquish a sacred value, the respond with “moral outrage, ” even though the proposition is not objectively immoral (offering compensation to remove Jewish settlers from the disputed West Bank in Jerusalem, e. g. ) Believers usually become even more intransigent. • When a value becomes “sacred”, the rules of negotiation change. For instance, the stakes must be raised, consequences of non-compromise must be dire, and both sides must give up something they hold dear.

Problems With Intuition • Intuition can be very accurate in many situations. However, intuition also leads us astray in certain ways. – We overvalue the possibility of regret. We feel losses more than gains. We don’t act. – The way choices are defined influences our emotions. (80% live vs 20% die) – We think more memorable events are more frequent. – Confirmation bias – we see evidence for what we believe to be true. – We find stories more compelling than data.

Gender • Are there real differences in the way men and women think about the world? • Probably. It’s just that we don’t know what they are.

What About Gender? • We all seem to believe there are fundamental differences between men and women, but surprisingly, researchers have found very few large-scale differences in brain structure or function. • Boys have larger brains (and heads) than girls from birth to old age. Girls’ brains mature earlier, especially for impulse control, language and fine motor skills. Brain scans show some structural differences. But since experience itself changes the brain, it is hard to determine what is inborn and what is cultural.

Biology: Testosterone • Sex hormone levels do not differ between boys and girls from six months of age until puberty, so differences seen in these years are due to either fetal testosterone exposure or cultural differences. • It seems that, on average, boys are more physically active than girls (31% of girls are more active than boys!) This is seen even in fetal movement. • In infancy, both genders like dolls. By toddlerhood, boys and girls who were exposed to high levels of testosterone during pregnancy prefer trucks and cars. This is also true with monkeys.

Biology: Visual / Spatial Skills • Gender differences in spatial skills are among the largest of the cognitive gaps. The average man can perform mental rotation better than 80% of women. This difference is seen in babies as young as 3 months and is probably due to fetal testosterone. • Some studies show that women use the prefrontal cortex (landmarks and geometric cues) when solving a 3 dimensional maze, whereas men use the left hippocampus (memory and spatial mapping. ) Women tend to be better at remembering positions and landmarks. Men tend to navigate by remembering directions.

Cultural Caveat • Women do worse at math tests when they are required to write their gender on their papers. Men do better. • Women do 30% better on math tests when they are reminded about what a good school they go to or how much they have learned. • Women, in general, perform better in college math classes than their aptitude scores would predict, and men do worse.

Culture: Activity • Mothers discourage physical risk taking more in daughters than sons. Fathers encourage more physical play and risk taking in both genders. By eight weeks, babies picked up by mothers will calm down, but when picked up by fathers, will show an increase in respiration and heart rate. • Peers strongly effect activity level: all-boy groups tend to be more energetic, girl groups tend to settle down the more active girls.

Culture: Play • Peers reinforce gender norms even more than parents. Girls tend to cross-over more than boys – they are encouraged to play sports, wear pants, and play with Legos more than boys to wear dresses and play house.

Biology: Aggression • Boys are more physically aggressive than girls. This is due to fetal testosterone, since aggression does not worsen at puberty, when testosterone levels rise. • Male bullies usually have few friends, act alone, are socially inept, and don’t know the boy they bully. • Under threat, men report a sharpening of senses and a feeling of exhilaration (sympathetic nervous system response) • Men tend to be physically aggressive and then bond after the fight.

Culture: Aggression • Girls tend to be more indirectly aggressive than boys. Gossip, ostracism, eye-rolling, and harassing text messaging can do great damage to peers. • Females tend to be aggressive by excluding and do not make up and bond after the fight. • Female bullies have many friends, are socially skilled, act in groups to isolate a single girl, whom they know. • Women report unpleasant feelings of dizziness and nausea under threat (parasympathetic response. )

Biology: Empathy • Girls and women score higher on most measures of empathy, but this difference is fairly small. Women are more likely to say they are good at knowing how others feel, but men and women differ little in objectively being able to read faces or voices – the average woman is better than 66% of men.

Culture: Empathy • Little girls start out a bit more sensitive than boys, but the advantage grows over time due to stronger communication skills, role playing with dolls, and having more intimate friendships than boys.

Biology: Language • Girls begin talking about one month earlier than boys and are 12% ahead in reading by kindergarten. By the end of 12 th grade, they are significantly better readers and writers. This difference shrinks in adulthood. • The superior temporal cortex (important language center) is 29% larger in women than men, but this may reflect environmental differences during development. .

Culture: Language • There is no neurologic evidence that girls process language differently than boys. Differences are probably much more due to environment and language exposure. Girls read more than boys.

Biology? : Language • Men’s talk tends to focus on hierarchy, women’s on connection. Boys are very competitive, girls will even imitate odd syntax when talking (“My babysitter has already contacts. ” “My mom has already contacts and my dad does, too!”) • Women may try to bond with a man by talking about problems. Men may misinterpret that as a request for help. He will then get blamed for failing to listen, whereas he cannot fathom why she would keep talking about a problem if she doesn’t want to do anything about it.

Culture: Visual / Spatial Abilities • The gap is smaller in children than adults. Exposure to targeting, throwing, driving and shooting games widens the difference. Girls improve if they are given these experiences, just as boys become more empathic. Women do better on 3 -dimensional rotation tests when they are told they are naturally good at it.

Culture: Humor • Both men and women look for a sense of humor in a potential partner. Humor is a good indicator of intelligence. What women mean is: someone who makes me laugh. Men mean: someone to laugh at my jokes. • Both men and women laugh more at men than women. • Men find women more attractive when they laugh. Laughter seems to be a sign of enjoyment and an invitation to continue. It is a powerful measure of the attraction between two people.

Culture: Humor • During courtship, men are usually the producers of humor and women the appreciators. However, in long-term relationships, the woman’s sense of humor predicts relationships that will survive. The man’s humor may be more detrimental (aggressive and disparaging. ) Women’s humor during tense discussions tends to lower a man’s heart rate and relieve tension.

Biology + Culture • Average IQ scores for men and women are the same, but more males score at the very top and the very bottom. • Surveys show that at rest, men are more attuned to the outside world, women to their internal state.

Dads as Parents • Dads are more stimulating to infants in part because they tend to be more physical and unpredictable. • Fathers are less verbal with their children, but fathers’ language use, not mothers’, independently predicts language development at age 3. The size of the mothers’ vocabulary makes no difference. They use more unusual words, talking about sports and cars, and fewer emotion words. • Kids who have stable and involved dads are better off on nearly every cognitive, social, and emotional measure that researchers can devise. The marriages are better and they are happier.

Dads as Parents • In many cases where dads are not functioning as active parents, it is because moms use their power to block fathers’ participation, acting as gatekeepers. This is especially true of women with low self-esteem.

Culture: School • In kindergarten, girls are more articulate, have better handwriting, and answer questions faster. • Girls outperform boys throughout the entire educational process, including college. • Men seem to be better at word problems, women at calculation.

Culture: Math • Boys younger than 13 scored 700 on the math part of the SAT’s more often than girls at a ratio of 13: 1 in 1983. In 2005, the ratio fell to 2. 8: 1. This is not “hard-wired. ” • At the International Mathematical Olympiad, top rated teams from Bulgaria, Russia, and Germany have 15 -20 girls. The US typically has ~3.

Biology + Culture • Men are more likely to compete and show off, especially violently, to attract a mate. This is true throughout the animal kingdom. • In terms of socialization, women have more intimate social connections, are more concerned about them, and feel more empathy toward friends. They smile and laugh more. They are more attentive to infants’ everyday needs, but not distress cries. • Women tend to maintain friendships based on selfdisclosure. In men, self-disclosure arises out of shared activities, often “rough-housing. ”

Biology + Culture: Pathology • Boys don’t see or hear as well as girls. Women are more sensitive to sound and smell. • In child mental health services, the patients are predominantly boys, suffering from autism, hyperactivity, learning disabilities, conduct disorders, and anxiety. Boys have more stuttering, dyslexia, stress headaches, GI problems, asthma and tics. • Parents have more difficulties with their sons. Teachers have more difficulties with boys.

Biology + Culture: Pathology • This all changes at puberty when virtually all psychiatric disorders (except substance abuse, schizophrenia, and impulse disorders) become substantially more common in women. • Depression and anxiety disorders are twice as common in adult women as men. Estrogen and testosterone have effects on serotonin and GABA that contribute to this.

Substance Use • The risk for substance use in adolescent girls is primarily related to peer pressure, and participating in sports is protective. • In adolescent boys, playing sports is a risk factor for substance abuse. Peer pressure is less important.

Biology + Culture: Pathology • Friendship networks are larger in women, which tend to buffer stress. • Also, marriage is protective against mental illness in men, but not women, who are more at risk after they are married. • Women, in general, act as caretakers of spouses, children, and aging parents, and may “pay the price of caring. ”

Biology + Culture: Stress • When humans are stressed, oxytocin is released in the brain causing increased bonding to others, nurturing of children, and increased calming. Testosterone reduces this effect, estrogen increases it. • Men often withdraw to cope with stress – watch TV, work on a project. • Women often process stress by seeking out more connections with people – talking about it.

Gender Differences • Response to stress – Men typically interrupt and give solutions when a woman is talking about stress, and say “You shouldn’t be upset. ” (This is a mistake. ) – Women tend to offer advice to a man when he is not upset and may be quite happy with what he is doing. This can cause a man to “tune out. ”

Gender Differences: Cultural vs. Biological • Men and women do not differ in moral reasoning, level of intelligence, or basic emotional traits. They share virtually all the same genes. • Men are not from Mars and Women are not from Venus. • Men and women are from Africa.

Summary: The Moral Faculty • Human beings are born with the parts of a universal moral “grammar” that constrains the range of possible moral behavior. • Human capacities that allow us to care about morality include: – – – Fairness Reciprocity Intuition about social contracts Empathy Moral emotions

Summary: The Moral Faculty • Each principle generates an automatic and rapid opinion about whether an act is morally permissible or forbidden. • These principles are inaccessible to conscious awareness. • Acquiring the moral system is fast and effortless, requiring little or no instruction. • Cultures “wire” these universal capacities in specific ways, associating different behaviors with our moral emotions. They become our cultural values: e. g. autonomy, spiritual purity, etc.

Summary: The Moral Faculty • It is the unconscious nature of the ethical decision making process, combined with the power of the emotional content, that makes moral conflicts so intractable.

“ PEOPLE WHO BELIEVE THEY HAVE THE TRUTH SHOULD KNOW THEY BELIEVE IT, RATHER THAN BELIEVE THEY KNOW IT. ” Jules Lequier

Research on Helping Others Become More Ethical • People who are emotionally secure show more empathy to others. They are more likely to to offer to do an unpleasant task for a stranger if they had been made to feel more confident. • Buddhist monks who practice compassion meditation develop more compassion in day to day situations, as measured by brain scans. • One person who refused to shock the participant in the classic experiment said he was raised in a home that taught him to question authority and in the army he was taught to refuse illegal orders.

Spirituality, Religion, and Worldview in Mental Health Care

Religion in America • Religious membership in America is higher than in any other industrialized country except Northern Ireland. There are 300, 000 religious congregations in the US – an enormous variety compared to the rest of the world largely because there has never been an official “U. S. Church. ”

Christians in America (Pew Forum on Religion and Public Life, Feb 2008)

America’s Four Gods Froese, Bader 2010

The Four Gods • This is for didactic purposes only. Most people have some sort of mixture. This is a generalization.

America’s Four Gods • Authoritative: We will lose God’s favor unless we do what He demands. God is engaged in human history and rewards countries that follow His will and gets angry, punishing countries that disobey Him. – Theme: the righteous vs. the heathen, obedience, duty, and the loving embrace of God, the Father. – Common beliefs: homosexuals choose to be homosexuals and are sinners; abortion is murder; personal faith solves problems, not the government; God causes or allows disasters as punishment, but will reward you with love and happiness if you are faithful.

Case Example • You are seeing an adolescent boy who is having some school and mild behavior problems, possible related to ADHD, as well as common adolescent rebelliousness. You like this teen, but the parents, especially the father, seem unreasonably harsh and rigid. During the course of therapy it comes out that the family attends a church that teaches unrelenting obedience to God and the tenets of the Bible as the only path to happiness and salvation. The parents believe if they let up on their son, they are literally condemning him.

America’s Four Gods • Distant: God is the cosmic force that set the laws of nature in motion, but does not intervene. God is not a person (God does not get “angry”, for instance. ) We see evidence of God in the beauty of the natural world, which was created, but now runs according to natural law. – Theme: God is the master watchmaker. A storm is just a storm. – Common beliefs: God may be a force for good, but we must take care of our own planet, our people, our future.

Case Example • Your client has come to see you for help regarding ongoing grief after the death of his 8 year old son a year ago. The issue is also proving to be a wedge between him and his wife, who has found comfort in talking to their minister. He has explained that life and death are all part of a larger plan, and that we must surrender to “not knowing” but also believe that God will take care of us. The husband, you discover, does not believe that there is any meaning to life or death; that the universe is vast and neutral, and that we are alone in trying to manage our sorrows.

America’s Four Gods • Benevolent: God is a force of good, and loves us, weeps for us in our struggles, and will support us through everything, even when we do bad things. – Theme: God is love and will comfort the sinner and the saint, the rich and the poor, the first and the last. – Common beliefs: God often performs miracles outside the laws of nature, but does not have a hand in disasters or tragedies, which are the doing of either mankind or the natural world.

Case Example • You are seeing a mother and daughter, referred by the oncology service at University Hospital. The 14 year-old daughter has been diagnosed with a life threatening leukemia and is undergoing chemotherapy. The mother seems positive, almost cheerful, and the daughter feels angry and dismissed. The mother keeps trying to explain that God and his angels are watching over her, and will take care of her, and that they just need to trust in His love.

America’s Four Gods • Critical: God will sit in judgment on human beings in the afterlife, but He is not involved in our day-to-day lives. This view is held most often by the poor, ethnic minorities, or exploited. – Theme: this world is a vale of tears. Our rewards or punishments will come in the afterlife. – Common beliefs: God has no role in the rise or fall of governments, natural disasters, etc. Don’t expect much in this life.

Case Example • You are frustrated in your work as a case manager with a large clientele of poor, unemployed clients. Many of them refuse to vote in the upcoming elections because they say it won’t make any difference, and anyway, their minister says, “Don’t you worry about this life, you’re going to be dancing on streets of gold for eternity if you just pray to Jesus. ”

Changes in the Last 15 Years • There has been a move away from mainstream Protestant churches to non-denominational “Mega-Churches. ” • Immigrants keep the percentage of Catholics in the US around 32% despite losses in the established population. • The greatest growth has been in the Evangelical Christian group and in the Unaffiliated group. • About 30% of Americans leave the religion they were raised in. 50% of Americans who were not raised in a church join one as an adult.

How Much Do We Know About the Different Religions? (Sample questions, all multiple choice, Pew Forum on Religion and Public Life, 2010, n=3, 400)) • • Who led the Exodus out of Egypt? (Moses) What was Mother Teresa’s religion? (Catholic) In what religion is Ramadan a holiday? (Islam What religion did Joseph Smith found? (Mormon) What is the primary religion of Pakistan? (Islam) What religion is the Dalai Lama? (Buddhist) Who was the important figure of the Reformation? (Martin Luther) Which figure represents the tenet to obey God in spite of your suffering? (Job) • Nirvana represents freedom from suffering in what religion? (Buddhism)

How Much Do We Know About Different Religions? (Pew Forum on Religion and Public Life, 2010, n=3, 400)

A Few Findings From the Survey. . . • 64% believe that you cannot mention the Bible in a public school, even as a topic of study. • 53% of Protestants don’t know who Martin Luther was • 47% of Americans don’t know who the Dalai Lama is • Only 27% know that Indonesia is primarily Muslim • 40% don’t know who the Vice President is, even on a multiple choice.

Psychological Research and Belief • A person’s religious feelings includes a genetic component. (It is known from twin and adoption studies that early environment begins to become less influential and genetic influences more important around the age of 18 -25. ) It is also fairly well established that the genetic component of personality consists of 5 traits: – – – Extroversion Neuroticism Agreeableness Conscientiousness Openness

Beliefs and Personality Traits Belief Extroversi on Agreeablene Conscientio ss usness Neuroticism Openness Religious High Fundamentali sm High Low High Low Spiritual High Creative Authoritative Paranormal High

Beliefs and Personality Traits • These effects are modest, but they have been found consistently by many different studies (Saraglou, Sci Am Mind May/June 2012). Specifically, the trait of openness distinguished between people who were fundamentalist and people who were more broadly spiritual. • Research also suggests that people are more likely to be religious if the community around them is religious (VT vs. MS, Sweden vs. Egypt). It is a social rather than individual force. • Finally, religious people are happier than non-religious, but only if the society to which they belong values religion highly and they have friends in their congregation.

People in Need • Americans are more likely to turn to religious institutions when they have serious problems than to the government or health and human services organizations. • 77% of those who seek medical care feel that their religious beliefs are directly related to their health concerns. • Only 16% of health professionals ask about spiritual issues.

Spiritual Beliefs and Your Doctor • 85% of patients trust their doctor more if the doctor addresses their spiritual concerns. • 95% want their family practice doctor to a consider their spiritual beliefs in the case of serious illness, 86% when they are admitted to a hospital.

Prayer and Health Beliefs (CBS poll, 1999) • 30% of Americans believe a moral life prevents illness • 80% of Americans believe prayer can help people recover from disease (2005 ABC and USA Today poll) • 50% of patients would like their physicians to join them in prayer. (Yankelovich 1996) • 63% believe a doctor should join a patient in prayer if requested • 34% believe prayer should be a standard part of medicine

Belief in the Supernatural: Pew Forum on Religion, 2009, n=4, 000

Anomalous Experiences • An experience that deviates from the usually accepted explanations of reality – – – Mystical Near-death Telepathy Clairvoyance Precognition

Mystical Experiences • • 30 -40%, increased during the last 30 years Typically last 1 -3 hours Ineffable Sense a unity of all things, timelessness, spacelessness, loss of self • Visions, voices, telepathy, contact with the dead, new sense of purpose • Often correlated with better psychological functioning, promotes healing and change

Near-Death Experiences • A clearly identifiable phenomenon that occurs in 5 -30% patients who are clinically dead and then resuscitated. • Patients report a continuity of subjective experience, including leaving the body, observing hospital events, passing through a dark tunnel, experiencing a bright light, meeting spiritual beings. • Long-lasting effects include stronger empathy, more involvement with family, greater sense of purpose, less fear of death, more appreciation of life

Sacred Moments • Many people perceive “sacred moments” in their lives – moments of transcendence (apart from the ordinary), boundlessness, and a feeling that a deep truth has been revealed. • Sometimes anomalous experiences become sacred moments to individuals. Other times, a perfectly prosaic moment may rise to sacred status. • These are not unusual. (For example, the majority of people who have lost a loved one report a continued connection with them – a voice, feeling a touch, sensing a presence, etc. )

Sacred Moments • We do not need to get tangled up in trying to decide whether these moments are factual, or to lose focus on the client by getting wrapped up in our own beliefs or unbeliefs. • These moments have significant power for many people. They offer the capacity to soothe, comfort, inspire and empower. They can provide individuals with a way to find meaning in life. They represent an important opportunity for alliance and progress in therapy.

Definitions • Worldview is an intellectual response to life’s most basic questions. It is one’s philosophy of life. • Religion is the form that spirituality takes within given traditions and involves a belief in God. • Spirituality is concerned with one’s connection to a larger context of meaning - that there is more to life than the material. In surveys, it has become hard to distinguish purely humanistic beliefs from those involving a supreme being or the sacred realm. There may be four different focuses of spirituality (or a mix!)

Four Types of Spirituality • Religious: sense of closeness and connection to the sacred as described by a specific religion.

Four Types of Spirituality • Humanistic: sense of closeness and connection to humankind, often involving feelings of love, altruism

Four Types of Spirituality • Nature: sense of closeness and connection to the environment or to nature, often involving feelings of wonder and awe.

Four Types of Spirituality • Cosmos: sense of closeness and connection with the whole of creation, often involving reflecting on the vastness and magnificence of the universe.

Philosophy of Life • The worldview of the patient and clinician contribute to the success or failure of the treatment. – Understanding the patient requires the clinician to know the patient’s worldview. – The worldview of the clinician influences his or her clinical impressions and judgment.

Research Problems of Religion and Spirituality • How do you measure religiosity and spirituality? – Attendance at church? Attendance at other church events? Frequency of prayer? Core beliefs and values? • Almost all of the studies are done as cross-sections, not longitudinally. How do these beliefs change in relation to health? Sudden change may be unstable over time. • We don’t know much about the mediators of R/S. – Social support? Secular vs. religious coping? Optimism? Selfesteem? Confidence? Motivation?

The Research: Summary • Most studies of religiosity and spirituality have been found to be related to reduced morbidity and mortality, better subjective health, and lower psychological distress. In general, they are related to less substance abuse. • Some studies have focused on religiosity and spirituality linking to feelings of guilt, shame, passivity, and coping in the form of prayer for vengeance and “righteous anger. ”

The Research: Summary • Studies comparing faith-based clinical care versus standard care mixed and inconclusive. 12 -step programs work better when the participants actively participate, rather than merely attend, but we don’t know how important the spiritual component of AA is. Increases in religiousness/spirituality during participation do tend to predict abstinence.

2011 Review of R/S in Therapy (Worthington 2011) • 51 studies, 3, 290 subjects • Results: – Patients in R/S therapies do better than in “no treatment” control groups – Patients in R/S therapies have better spiritual outcomes than those in other psychotherapies – Psychological outcomes are the same for R/S therapies and standard therapies – Independent research indicates that accommodating patient preferences modestly enhances treatment outcome.

Spirituality Effects Health – Positive • Church attendees with sickle cell disease had lower scores on pain measures (J of Nerv Ment Dis, 2005) • Personal devotion and conservative religious beliefs were inversely related to substance abuse and dependence (J Am Acad Child Adol Psych, 2000) • Most associations of religious commitment and mental health published in the professional literature are positive (Am J Psych, 1992)

Spirituality Effects Health – Positive • Religiously involved youth are less likely to be antisocial (J Soc Issues, 1995) • Adolescents’ religious commitment delays the age of first sexual intercourse, but also makes contraception less likely (J Marr Fam 1987) • Religiousness is inversely related to anxiety (Prof Psychol Res Pract, 1983) • Religious injunctions may encourage people to live a physically healthy lifestyle.

Spirituality Effects Health – Positive • A 2011 study of alcoholism treatment found that in 364 people (mean age 44), changes in spirituality and religiousness predicted decreased drinking and fewer occurrences of heavy drinking when drinking did occur. The effect was independent of AA participation. The specific associations were with learning to forgive yourself, praying, and stopping seeing oneself as punished by God.

Spirituality Effects Health - Negative • Countless people have died because their religious beliefs have led them to refuse medical care (Christ Sci, Jehovah’s Wit)

Spirituality Effects Emotional Resilience • Elderly African Americans with religious involvement show higher levels of personal growth, self-acceptance, positive relations with others (J Couns Psych 2005). • Religiosity predicts shorter time to remission of depression (Handbook of Religion and Mental Health, 1998) • Personal devotion buffers the effects of life events on individuals prone to depression (Am J Psych, 1997)

Spirituality Effects Emotional Resilience • Being religious is associated with less depression, better self-esteem and better self-care among family caregivers of persons with serious mental illness (Psych Serv 2006). • Religious coping in schizophrenia (Am J Psych 2006) • R/S has a protective effect against the development of depression (Am J Psych 2012).

Schizophrenia and Religion • 100 clients • 61% Christian, 9% other traditional religions, 12% from minority religions (Christian Science, Scientology, etc), 18% no religion • 56% did not practice with other people, 14% occasionally, 30% regularly • Religion was important to 85%, 45% said it was the most important thing in their lives. 78% said it was essential in coping with day-to-day life.

Positive Coping - 71% • “I always have the Bible with me. When I feel I am in danger, I read it and I feel I am protected. ” • “For some time everyday, I feel other people can control me from a distance. The Buddhist monk told me it was only my imagination, and he teaches me how to meditate. In this way, I distance myself from this idea of control. I tell myself this is just a symptom of my illness. ” • “If you tell yourself that you have an eternal life ahead of you, you know that the voices will end. ”

Positive Coping - 71% • “I am anxious about meeting people, so beforehand I pray that everything will be OK. Then I am confident in the situation. ” • “When I feel despair, prayer helps me find peace, strength, and comfort. ” • “My life did not turn out like I wanted. I dreamed of being a movie star. I do not have a wife. I am unable to work. I have been hospitalized against my will. After all this, I consider myself happy. God gives me all I need. ”

Spirituality And Happiness • Three character traits have been found to effect our overall sense of well-being: – – Self-directedness (responsible, purposeful, resourceful) Cooperativeness (tolerant, helpful, compassionate) Self-transcendence (intuitive, judicious, spiritual) (Psych Annals 2006)

Schizophrenia and Religion • 100 clients • 61% Christian, 9% other traditional religions, 12% from minority religions (Christian Science, Scientology, etc), 18% no religion • 56% did not practice with other people, 14% occasionally, 30% regularly • Religion was important to 85%, 45% said it was the most important thing in their lives. 78% said it was essential in coping with day-to-day life.

Positive Coping - 71% • “I always have the Bible with me. When I feel I am in danger, I read it and I feel I am protected. ” • “For some time everyday, I feel other people can control me from a distance. The Buddhist monk told me it was only my imagination, and he teaches me how to meditate. In this way, I distance myself from this idea of control. I tell myself this is just a symptom of my illness. ” • “If you tell yourself that you have an eternal life ahead of you, you know that the voices will end. ”

Positive Coping - 71% • “I am anxious about meeting people, so beforehand I pray that everything will be OK. Then I am confident in the situation. ” • “When I feel despair, prayer helps me find peace, strength, and comfort. ” • “My life did not turn out like I wanted. I dreamed of being a movie star. I do not have a wife. I am unable to work. I have been hospitalized against my will. After all this, I consider myself happy. God gives me all I need. ”

Negative Coping - 14% • “I suffer from being so isolated. I went to church in order to meet people. But when I read the Bible it disturbs me. I begin to think I have behaved wickedly and then believe I am the devil. ” • “I went to church to be healed. I believed Jesus would help me, but this is a lie. More problems came, like a curse, God is a cruel God. I want to die because I suffer too much. ”

Spirituality May Be the Focus of Psychiatric Illness • Clients with psychotic disorders frequently incorporate religious delusions and themes.

Psychosis or Religion? • Patients with religious delusions demonstrate intense belief that occupies their entire thinking. They tend to endorse details that exceed traditional expressions of this belief. • Functioning and behavior typically deteriorate. Other symptoms of psychiatric illness can be seen.

Psychosis or Religion? • Religious delusions – Persecutory: usually involving the devil – Grandiosity: usually involving God – Belittlement: usually involving unforgivable sins • Many practitioners are concerned that addressing religion may appear to support delusional thinking. (Spiritual Competency Resource Center, www. internetguides. com) When on unfamiliar ground, getting consultation with appropriate religious authorities may help.

Spirituality is Fundamentally Related to Suffering/Meaning • The task of putting suffering into perspective requires that therapist and client grapple with larger questions, e. g. a person who has always believed and trusted God to take care of him/her may feel betrayed or even punished if he/she experiences grave misfortune. (J Psychother Pract Res, 2001)

Freud • Freud’s worldview was strongly materialistic and dogmatically atheistic, which fueled his intense lifelong attack against spirituality. He believed religion was childishness and hoped people would soon outgrow it. (“God is nothing other than an exalted father. ”) • “Religious people lack qualities essential to mental health. ” (A. Ellis, 1983)

Spirituality and Psychiatry • A recent survey shows that religious physicians may be more prone to refer distressed patients to clergy or other pastoral counselors rather than to psychiatrists.

Changing Times? • A 2007 survey of 2, 000 psychiatrists indicates that psychiatrists are more likely than other physicians to address religion/spirituality in the clinical setting and do so comfortably. • 75% of psychiatrists describe spiritual influences as positive (slightly higher for other physicians. ) • Psychiatrists (82%) are more likely to say that religion can also have a negative influence than other physicians (44%. )

The Clergy and Mental Illness • The clergy serve ~40% of Americans with mental health problems. In fact, some studies show that they are more likely to be sought out for guidance on mental health issues. Women, people who have been widowed, and the elderly are more likely to seek out clergy. • 50 -80% of clergy report their counseling training in seminary as inadequate, yet less than 10% referred those counseled to a mental health professional. In a recent study, almost half of 98 surveyed clergy members failed to recognize serious mental illness in 2 vignettes, and said they would not refer them to more professional help.

Doing the Assessment • • Deal with personal discomfort Listen (receive, appreciate, summarize, ask) Be prepared to answer questions Be aware of countertransference

Private Matters • Spiritual beliefs and feelings are usually private and held to be sacred. A trusting relationship and good treatment alliance are crucial. • Treaters need to be aware of their own beliefs and at the same time increase their awareness and empathy for other spiritual traditions. The clinician’s primary goal is to promote the client’s self-determination and not be a missionary for any particular value system.

Screening: FICA • • F - Is religious faith important to you? I - Has faith influenced your life? C - Are you part of a religious community? A - Are there spiritual needs that should be addressed?

Developmental History • • • First religious experience? Religious training? Similarity to parents’ beliefs? Any traumatic religious beliefs? Conversion experience? Desires for spiritual development?

Community • Participation in church, synagogue, etc? • Have you changed churches and why? • What support have you received?

God • • Belief in the existence of God? What is God like? How has your belief influenced you? How do you experience God?

Belief • • • Single most important religious belief? Beliefs that you doubt the most? Beliefs you doubt the least? Your understanding of suffering in the world? What is a life with purpose?

Rituals and Practice • Prayer? • Other private religious practices? • Attendance of worship services?

Spiritual Experience • • Any spiritual experiences? Impact on direction of life? Have you told others about these experiences? Importance in daily life?

Fetzer Assessment Tools: www. fetzer. org • • • Daily spiritual experiences Meaning Values Beliefs Forgiveness Private religious practices Religious/spiritual coping/history Commitment Organizational religiousness

Spirituality in the Clinical Setting • The first step is communicating a genuine interest in and compassion for the client. • When clients talk about anomalous experiences – Provide support without judgment – Focus on how the client interprets the experience, not whether or not it happened – Normalize, if possible

Varieties of Therapy • Some clients want religious/spiritual beliefs accommodated in treatment. Some clients will accept secular treatment. Still others who are willing to be in secular treatment, might benefit from treatment in their R/S framework. • R/S psychotherapy will share the same goals as secular therapy, but will also incorporate methods and goals that are R/S in nature (prayer, religious imagery…) The therapy may also include goals of a spiritual nature (being more like Jesus, following the 8 -Fold Path of Buddhism…)

Examples • Christian–Accommodating Cognitive Therapy for Depression • Spiritual Self-Schema Therapy for Addiction • Christian-Accommodating Forgiveness Therapy • Muslim-Accommodating Cognitive Therapy for Anxiety

Potential Transference Problems • Clients may respond to therapist like a religious figure in their life • Clients may be ashamed in the presence of a therapist of their own faith • Clients may be suspicious of therapists who do not share their traditional values • Practitioners need to remember they are moving into emotionally volatile ground. Some clients have experienced harsh or punitive forms of religion, or abuse at the hands of authority figures.

Countertransference • Some of us have a difficult time bringing up the issue at all. • Under the influence of religious countertransference, a clinician can begin acting rigidly and thoughtlessly toward a client, as if the client = religious beliefs. This obstructs therapeutic relationships, obscures treatment options, and demeans the humanity of the clinician.

Potential Countertransference Problems • A zealous therapist may feel compelled to convert the client to his/her beliefs. • A therapists from the same tradition as their client may be tempted to act as a spiritual mentor. • A therapist might recoil from a client with spiritual views that therapist finds repugnant.

Negative Countertransference • Antidotes: – Work toward experiencing the client as a complex human being – Consciously utilize expressions of respect – Show interest and listen attentively • What life experiences made this an important belief? • What was your life like at the time? • With whom do you share this belief?

Potential Countertransference Problems • Therapists have been shown to pathologize beliefs that they do not understand (karma, primary importance of the soul, angels, what happens after death is more important than what happens during life, etc. ) • Therapists may underestimate pathology in clients who do share their beliefs.

Boundary Basics • A boundary violation can occur when therapist uses the power of therapist role to advocate for a specific religious belief. • Self-disclosures should be kept to a minimum because of the power differential in therapy relationship. Clients may agree with therapist’s personal spiritual approach because they fear their care will be compromised if they disagree.

Boundaries: A Conundrum • Clients deserve to know how therapist will respond when he/she hears about the abortion, homosexuality, religious beliefs, moral failures, etc. that are part of the client’s history and possibly part of the chief complaint. This is an issue of informed consent. • However, many clients want to know more than therapist feels comfortable sharing, for personal and therapeutic reasons.

No Clear Answers. . . – There are no clear answers. The classic approach is the safest: when a client desires more information about therapist, the follow-up should be an inquiry about the significance of that information for the client and therapy. “How will this help you get better? ”

The Request for Prayer • You work at the Dean Clinic. A 45 year old man is seeing you for an anxiety disorder and some career problems. He is not psychotic and there is no evidence of personality pathology. • At the third session of therapy, he requests that you join him in prayer. He explains that he is a Christian who tries to incorporate his faith into all aspects of his life, and wants to invite Christ to participate in his healing.

A Brief Review of Ethical Decision Making • Ethics is a branch of philosophy that involves the analysis of the moral value of judgments and duties. • Interest in ethics as a field of study has ebbed over the centuries, but has been revived in no small part by the growth of biomedicine in the second half of the 20 th century. • Today most ethical discussion is framed as a contrast between three ethical systems: deontology, utilitarianism, principlism.

Deontology • Deontology is an ethical system based on duties and moral obligations. Religious laws generally impose a set of obligatory behaviors that are right or wrong in and of themselves, regardless of the consequences. Religious “commandments, ” Kant’s “categorical imperative” are behaviors that are universally binding. – Tell the truth – Prohibitions against abortion, transfusions, divorce, murder, eating certain foods, etc. – Love your neighbor – Etc

Utilitarianism • Utilitarianism states an act is morally right if it imposes the greatest benefit and imposes the least burden on those involved. The end justifies the means. However, it is often very difficult to calculate the consequences of particular decisions. – Lying is morally correct if it saves a life. – Killing may be justified for a moral cause, like self-defense or in a just war. – Stealing to get food for your family is part of a higher duty.

Principle-Based Ethics • Principlism is an attempt to reconcile the discrepancies between utilitarianism and deontology by linking moral decision-making to certain principles. This is what is usually taught in ethics seminars. It is not strictly a theory and it is intrinsically vague. It is also not hierarchical. It is an effort to make ethics more practice friendly. • Four principles often used in medical ethics: – – Non-maleficence (no harm) Beneficence Respect for autonomy Justice

The Request for Prayer • Do no harm – Transference – Countertransference – Boundaries (Is this what a therapist does? ) • Beneficence • Respect for autonomy • Justice

The Grieving Mother • You are a therapist for Group Health. Your client is a 33 year old mother who is experiencing ongoing grief after the loss of her 4 year old son in an accident 2 years ago. After several sessions, it is clear that a big part of her turmoil is her loss of faith that there is a God who watches over us. She has talked to her minister, but remains at a loss in how to understand what has happened to her, or if she is being punished for her sins. • She asks you, “Do you think this is this part of God’s plan? Am I being punished for not believing? ”

The Grieving Mother • Do no harm – Transference – Countertransference – Boundaries (Is this what a therapist does? ) • Beneficence • Respect for autonomy • Justice

The Angry Teen • You are seeing a 16 year-old girl in family therapy at UW for school and behavior problems that have worsened in the last year – smoking, poor grades, defiance at school, anger alternating with tearfulness, etc. You get the feeling after spending time with her that she is yearning for some support and affection from her mother and father, but they are consistently harsh in their comments and discipline. In your opinion, this is making the situation worse. Their minister, however, clearly says, in a letter brought in by the father, that the girl’s behavior is sinful and that she need to renounce her behaviors and ask forgiveness.

The Angry Teen • Do no harm – Transference – Countertransference – Boundaries (Is this what a therapist does? ) • Beneficence • Respect for autonomy • Justice